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BEMIOLOSI-N NEU ROLOGICA


PRETATA
Probleme d,e cl,iagnosti,c topograJic pi. etiopatogenie Ln: l,eziunile nerailor cranieni,, paralizii, tulburdri d,e tonus muscul,ar,, ataaii,, migadri inoolunlare, lulburdri de sensibilitate,tindroame algiae, tulbnnd,ri troJice, agnoeii, aJazii,, apraoii, tulburd,ri de conptiittld, gi gtsihoorganice,

pa o eaperienld,6nd,elunPd,rereanoastrd, baza,td ltatd' estacd orice semiologied,i.norice domeni.umedical rute bi,nauenitd, iar d,u1td,apari,l,ia sa se {Lftee?tii cu erd,bilare sd, aind, o akd, semiologie cu acela,siproJil. Orice semiologiepoale li a4tusd, 4,tr, mriate feluri. pi. cste ind,epend,entd ile altarilia ao , nui a tratatalor iJe aul,a7i, profil. Deoarece 4n literaturt med,icald,uniwrrald, sdrtl d,estul de pwline semiologii - noi ored,em ritr sl,nt mai. d,i.ficil de sois d,eaiturl tra,tat - e bine a w scrie cl.tr rnai. rnult, cd,ci fiecare clinician, d,apd, rtttt4tcytf,ia Si enperi,enla3&, o Da scrie nntr-un alt mod d( {ltnd,ire. Nu trabuie sd, surprindd, pe nimeni, apari,tia ce dtrinele librduoe ci $emiologii. Neurologice, d,ugtd, rii.l,or au odzut 4n acapti.ultimi d,oi.ani llratatwl nostru d,oN ettrologlienn cinci uolurne. Aceastd,carte a noaatrd pinq da.fapl, sd, umple un gol e*istent:l,n aetiaitatea th pi au pi o, nxed,ieilorneurologi,. neu,rochirurgi ',,si - medicind' generald, inlerokiat da fl,l,tespecia,litd'li, ,niil,il o,tt,alte cuvi,nte oricd,rui' clinici'an ind'iferent d,e ptojill yeaum Fi tn a,ctiDitatea,d'in 4nad!'d,m'i'ntuluniacfd'l/j.r pi !)ostuniaersitrar'Ne-anz gtropus sd aborddm, mai practicd'., o alNd'morl'al,i'tata, ln pogini,l,o o,oestea, itre anpunere a rnatari('lul,ui serniologic, nai qfioCan'ld,, ?lrrnlnil da I,a dmptomul' iaolal, tau tn' conteatul.rnai hrg pl alungtnd La boald, In nocaato oonstd'noulalao,. ll - ortdql|n nod - nli0l6tNta odrlii nonntre, 0iti'lortt'1,

,t)u, putoa, ila bnbinnra n ll,nt. lnltlni toala noilalitd,l'il'a ila ternneou lllo diagnottia, oara o sinl,aal, Tttomotror, d,a diann,orfliad, td-l orientezainreiliat 4,ntr"o ileci,zi,e l,arapuulicd' atlcc' [nlr-o atitud'i'ne urgenld pi,,itnTtldoit, I'n sistamatizarea tatd. XmTinim, grrin munco d'epusd' praat'ied' dndalungatd' a,castui, material cara refleotd,o tra patul bolnamr,lui, 4,ntro asid'ud, actioi,tafiaalinicdl un d,eaidaat major, dltctatrd'e misiwnea med'isttlu'i cd' practiciatt,: ajulorarea bol,naawlui. Nd'd'd,iilui'm sarai,ni' aom wtili nobi'lei' prin acea,std, carte ne Jace med'ical,d, tn fald,, 4n sistemulnou d'ed'sistenld' cnrene std, patria noastrd,. d,i.n
AAIORII

CUPNI,NB
l. lrlr|durnto h lezl[Dlle ncrvll'ol cioslonl l, ln)lrlnmc di dloUnostlc topogrnllc tl etloPAtogonlo I . lr.rtologld :t,1. Percchli t.t, l,utologl{ Pclechil a II-a " ' " ' r " l.ll, l:robl0nlo dc diagno6tic ln exottalmii otorii oculo patologie sistemelor tn dlagnostic ) dc ' ' ' ' Itrottlor l.l. l.h, Prohlorno de dlagnostlc lr! patologia nelvului trigemen Li lrroblGt o dc diag:nostic ld patologiA nervului laeial (cochlear) ' ' ' L?. lintltlnnrc de diagnostic in patologia nervului scustic g,l, t robklrno do diagnosttc tn patotogis slctomului vestibular t,g, l1$ltonrc dc dlagnostic in patologia nervulul Slorofaringian ' ' ' ' ' l.ltl, I'robl no dc diagno8tic ln patologia nrvulul pneumogastric ' ' ' ' l,ll. lrobl' rtr de di{gnostic ln patologia nexvului spinal Lll. t|rot,l(uc dc diagnostic tn patologia nervului hipoglos paraliziilo! rnultiple ale nervlor 'J,lil, lrro}|lrnrc do diagnostic in patologia r'flrrlr!rl bulbari l, }ltrtlrtlr do dlo0trostlc In parallzti ll,l, llrDlofltrcu scnlologic{ a delicitelor motolil 11,2,ltllnrh0roo t0lsclor pareze sau Paralizll !l,il, I'rohl{ttlo do dlognostic etiologic ai topograllc ln divo$e pamli'ii ' ' '

0 t0 TO t6 g? 40 78 84 92 0tt 11r 116 t 18 [10 721 183 13S 194 19t 168 i08 170 r80 180 [81

h tulhurirlle tonusulul mu6euhl L Fmlhrnr dn dlo0nostle


a,l, llholonlllo musaulare . a,t, lllDfrtorllo mucoulqre . do dlo0trostlc h ottrxll l, litltenl$ ll,l, FrobLrrno do mctodologie seiniologica }1, PmllloDro do dlegnostic etioDatogonlc ti topogratic tEvohtlt[lr ao ilhgnorilo tn semlolo0la ml|oitllof l, ltrotlmr

' '

'

' ' '

||l, !llDrrlhrorlllc 1,9, l)lrtonlllo l.S,0onvul.tllo l, ?nltror dr dle0Do.tlo h tolburlrllc do i'rtlb lrob do sandologlo t,t. nloonundlrl mctodoloSlao ?,3. Froblomo d0 dlsgno0tlctopogtqllc $ otlopqtogenlc' ?,!1.Froblono do dlngnoltlcottologlotn dlvo!'so ilndtoamc atglco ' ' ' ' ' l trulhur do lth0Do.tl0 tn iuuurtrlllc troll0o do orhhr lirlor|' t,i, ?ulbt|rdrl trotloo alo plolll, al6 frnelclor $ ilo lo'uturllor $ol ' ' ' ' l.!. T lburirl tt0tlor orteo0rtrlcuhr! l tl. Tdb$rirl trollco nrurol|lo$

101 191 100 ,08 210 t10 ,16 It6 246 ,46 !{t t02

9 . l "o l, lonrn

dth x,^ti. 'tn 11.l. A gln)z ii l r l . r r c t i t o l ).:1 . t J noz i i i c v i z u a l c :r.;J . glloz ii L ! : r u ( i i t i \ c

I n r r 0 r ,o ztl

270 27(t 275 276 2'.19 2',7 S 275


siurbolurilor

l )..1 .A t jnoz ii l e i n l a g i n i l o r . c o r p o r a lc I0. l|rubll.|Do dc diagnostic in tulburdlite d0 vorbiro gi lD afrzil t().1. c t ls iiica r c a t u l b u r : i r i l o r d e vo r b ir c Io.:1. ' l Ulbrr f i r i r i i r ] t r c p l i c i , r, . r L.rlc

1O.2.l ulbur.;iriale rnrisiunii si arliculirii cuvintelor

co n r p r r jh cDsiu n ii,Io r Dr u tir ii

si rfxp}esici

I t. |||rttrnr(! dr,d i l , D o s l i c i t l l r pr a \ii


l l .l . I )f f i| lit i i I 1.2. l, l\ iur)cn u l l l p r a r i i i l o i . . l l .:1 . lirrJ l, l(. r l i i c c . . t 1 c a p l ,a r iir i l i: . Prrbleln( rlr { l i r l l n o r t i ( i n l u tb u r ir ile ite co n lti( a ti ( r u n o stilr i) l :1 .1. l, rir)ril) i j l f r n f i { ) l t o t o p i { r csr r r io to g ice J d e d ia g u o stic e tio lo g i c si topogr:rti c I il. l i rl b ur' t iri t )ri h o r , r r f t r i . r , . l | r t , ( l 1 r i ! ( i e l e z i u r i ir 1 n u clcii b a za li l i l .i l . s ; ndr. )u r r x , ( h t c c l r l L : ziu n i co r ticu ic I:1 ..1.SiI (lrrJ l l r c i h t f r t r j c z i rn j d ilu zu l :l .l ). l. iiudroa n r c ( t l t c ( l r l o z i ur i situ ste D .\,.r r ia tc e tr jc

282

1.INTRODUCERE

295 ;J02 J02 315 :\,17 3.19 :i51 352

:1,,,1", lll]..i :1.:J . Sirx lro

,' (tiro.lr ieziunitc ,tiIlp,,";", *.,1r...;";.; *u.,,,*,,,,i., ,,""0l"i

' ,r rr i rl r,r' r l rtl l rIrv l Ii , i tr:ri l l0 r lf 1t r lt lc, isc vlt , 1: kt o t t t r t r xit r t t r , t t llit t i0 trl r i . trl r r,rrrr ci ti 0 i tr rrui srrt ir $ii, ( xi( 't t l. ( r zt . 1xr 0lir r it . iir r rlr l gr |lt ir r t , r . sl, i', t,rl rtl r' r | | III:| (,Ii | | i ru.t.l rrrr l tr' l rtrit . r r f r . r r lt I t lr . .

Penlru a veni in spdjinul rnedicului practician neurolog ll, llll llrr)plfssii scriem I en?,iologie neurologicdd,eurgenlii, itt <:lra ^ceasita rl'r rrrr .r rrrr prezenti,m in mod analitic ttiversele semne subiective ;i ,,r'r,, tr\ r.ir, irr numeroaselesemiologii clasice,ci sd,sugeri,m qi si, coltil_ '.. r rrrr rrrrrIIr1,IlIl posibilit5,ti diagnostice sindromatice qi de boa,li,,porninri ,lr lr , rrrr.lrrqirrelementarS, cu alte cuvinte Sd,potnim de ln sint|tltrnt, ,l | ,rlrr'., rr ll, boaliirla diagnosticul neurologic, care si, perrlliijti iur(r(lirLl rillrr,.r rrrrr.i rr,iil,rrdini practice,de urgentf. .Irebuie sd pornirn dc la irlrtlr, r.r ,lr,,"r', lrrrrl nelrrologic necesitd,cunoa$tereaunei semiologii prlcisr., r r I rr.,, r, ,r urrli discipline aproapo matematice. | | , lr,,, I rrrl,ua5, metodele paraclinice modeme de rrrin,cDrrrcrzrc L| ,r, clasici, $i cea inrlrogii(ilir ' rr ''rli ll[ {iaele (electloencef:}lografia , rl,, 1,"1, rrrri dc informatici, scintigrafia cereblali,, ecoenctl rilonr.rr I.irr, rr , rl' rr\ , rligal,ii ultlasonice, angiografia celebrald,, studiul cfixrirrlrri lr,,t,t,l,', lrrr'rrrnot'ncefalografia clasici ii frac.fionatl, angiogll,{irrspi,r ,l , , l,, lrorrriogllfi:r cu rirultrplelesale adjuvante, elcctrodiagloslilrrl rlr lrrrrrrlr,r'r'ri rlo dctec!ie si indeosebielcganta,miri{ica, spcctacuLlltsr r,,r,,'j,r.,trirr,irrli rornputelizat:'i cimpll ilc inrros ) au liirgit considerabil lt1, 1,, ,,, ,i rt(,l[]gio fi in neurochir.urgie. Cu toa,1e &coste&, c)itl,it ot,(,I iuitr.it, lr,r rrr lr.rlrrr(i;i plccizie nu pot sd,,,dctrongzs', exandlul clinic, rr rli,rrti ,r,,,,,r, rr rr:rr'irilrrlri, fine{.etlebuirr si, rliri jcze al,it indic:r,{iilo nr.l,,rlolrr lniti SuS, ciii fi iusta,it)tofpr.cltt,c l', ,, 1,||,.,, \ l)r'rio lt cer'C0t?il,ii insirr.rrrr0n I lr ' 1,r i, ((( l{,{ i.rl(, rlcl(jdf, (:,t:Li;lrc,clitricianulntr ltolltc llpsi, rrl nrt rlin cinrliul rlr, ltrplli, trrtl,otlologic rll(xl(r.11, |,,,r1r,lr ,,r'IrrrrirIrrL)' rlru:nioi (xtlij{t)i')) rlr"r,iillrr nrol'odologill trr lrrrrl. lr rtlrxl0r'rrii. Nrr lr.olrrrir ',lirsrr,l,

l ' l l l tr' l i trtri i n.l l n.nrl t t tii ( r t t r lcot r lr i vir t lit 't ', t t t t t i r t lt 't i glilt it lr ') , r : it t l l " ,l I' rtrl rrr.r' rrrrvti l ,r' ol l rrc livo r t r , t t lr zit t t t i t ir t lt t cr , l: r I ilr '. llillt r t ir t , llt t o l trl rl ,r , .| | |r| | | | | r(' i I 11i :rl l r, i tr[.r '( ii gct r ollt lo lt r r l, pt 'ot lt t r t 't ll ilr lt t t lt t t r il t t t r vtilr ' r,l l ,r, l rrr 11/rrrr ruorri rrgor,r r r r r 'l: r lilr Sr '. '1xr l, ir r lJlt r i t t t lt t it t gr t t 't t r r cf llilr ,( pt t t t t l rrrl ,. l trl rr,r' rrrl rrrrsr' ,l rrtrl ilr ') , ( . 1( jr , f r r lif t \r , ir t t l'ict ', t t t ct t it t gilr r r r 1t ir I t r I I r icr '. l l l ' l ' trtttl ttl i sntr: (l ( t!l, r r t . il, ir lii t : t : lu. l, iorr:,,t t r livlr so I r t 'r t lizilr 'i r yi k' rtrrrr , l rr' l rrr rrr i rrl rrtrrl l rt r r :lr r ,illr t t t ir lci r ir zll( f , ( '( lt 't it ( tl, I lt t t r t r t lit u'illl zt r r r i rl l ,r. l nr,, l l rrcl rrl i rrkr l l rtrr ci cit r t r t if ir r t , r lt noit lr t lui ( cu lt 'zilt r r t l f ikr t i'lr r l rl l r,,i rl t\ | | l r. | |(,| | r'()| | i | ()r' l xrlilit |'ici I i, ov( t r l, lliLl,ou sl|plit inr 'f l, t , ii st , ct t t t t lit lc osr niilo po$t - lr : t um a l ioo pl) 1, t '( ! ( it t lloit I lt C' PROBLEME DE DIAGNOSTIC TOPOGRAFICrt rr \ rl r. ,rIl ;rr.Ii vr' ). l Jrrcoli r ur r1lrr l .rrrrrrl l rrrrrurrri l ctLl i , I ) lir ( x) nt lr llovii, ur i, lr , bulllului t t lllt cl'iv r yi/ sr t , t t 4. $I ETIOPATOGENIC iN LEZIUNILE rr Irl rrrIr'Ir.Ir,Iololluclivrr. AllcoI'i ba,ndelotcle ol1'active pot' Ii lozrr,l'oplitt NIiRVILOR CRANIENI l l r,,ru. pl rrl i ;ri Lr rni ci ul c slonojdului. Jlxist l sil, t t a{ii in t 'at t t r it t ot t t st t l it|"r Irl'.rr''r1ii rroU r'ochiru] gio c, ridicarca lobuluj frrrulal pttillo ltftrt'l,a I rrr t rrI r.Ir' I r.I r, rrllrrr,livtr, (iilro se atlal po l:a!a, inl:orioru'i, a, lobulni orbilrrr. A l l ,.,,rt, l rrrrrrurl i srrrcl c, dat li leziunilo vasculluc lot ir nt l'olr r lupl, ur N' Intlad,ucere, Fatoiogia nervilor cranieni este deosebit n'||r ,r lrrrrir 1r|rIicrrIrrIrrivnscular provcnilj diu artur:l oerobralil ruti;trl'ittit I l't. Irogu,l;ri, de rl,rial5,, atit stb proceselor ryi morbide xesponsa .aspeetul r,r, (Dr*loix r 1l)l-;$, r. rlr. r';i frilrtt'fla, rr vrrscrrlrrtizeazii bulbul olfactiv $t[r aslrcct,rrl fi contiguratiiloi ;i al contextelor patologice '.it, fi I l l ' rl l rl {, l \l rl r16r.scu, 1l }?5) . .\r:r.:r,:,t,ir, .\cr.irtrir,ir comploxitc,te patologrot, oomplo-xrrc,re patologict, d.e de multe multc ori luxuriantx luxuiianti, si, qi cler ' | ' rrrrrrrrrrIrrrrrrr' |c (l(,1;{runrnatrr, cl ani o-cer ebr alo pot ploduco r nosm ii, hiposnr ii, t l: r l ,.,r1,'\ pe dc o parte de pozilia strategic[ a nuolei]or de r.rrr:ostrri i i ha luoina, lii olf aot ive. rl trrr, rr,u tlo 1;crminarein trunchiul cerebial ;i in iorma.tiunile Ir| | | | f S l,r,l lrrrrl,. lr:rzci craniului artreneazl tlcstul ilrl frecvent hipo- srttr rulitoonto &cestora,
.l l l l rnl l rl l

porrl;o-ocrebelos, in stlnca rrtrr rorfiirnrgicalc.

2.1,PAT0L0GIA PERECHII t tNERVUir 0LFACTIV)


rrorrrolol;lo lrxt[ intogritatea neuronilor gi n ciilor ollaetivo, esto vorba dlrosrrrii rlo nnturd ("Miloqescu,1925; Chusid, 19?0 ; Rir _rinolog,ied - Acestoa se caractorizoa,zd, llll"r9.;l'opoyiciu.Fi Pascu, 1.980), pril'anos

ll.l.l. tn prozonla unor disosmiila indivizi la caroun eorocr6xam

1,11111111111rr 11iN i ccol l i n i ( 1958, oit a, {, i dc }I iloqescu, 1975) a, u ar i, lt t l i,ll | | ||| i , | | I rI I t .rr r.rrlcfalopatiilor posttraumat'ico oonsecut'ivo ltziunilot'r'olt ' ItDl,,rllrl, 1rr,zrrrl:i in contextul clinic tulburlri scnzorialc, inclusiv aartsrnii 1rrr rrprti xi m at iv 10o/ o din t r aum at ism ele clllnio- cor ol) UlL' Ittul l t,rl rrrl rt, fl ' l r ' I l l i ,rl ,)ntl ttt r(l r:ul ur ( cer cbr a, Le ant leneazi, r ar 'eor i t ulbr t lir li r ) llir r ' \rrrrrrl r.i rrrrl rrrl rti ol cI ochzia pediculului vasculal pr ovollil, ( liI l l l tr, rttl r' rrr r, l l rl rl rr l rrl r,ri ol rl i , calo vascular izazi, bulbul olf llel iv ( I ) r xlloir tl l ,l l r, r, r, l l rl rH , (l i l rr{i rl e 1! liloqescu,1975) , poat e pr oduc{) r ln( , Blnjo. lll Itrh nrlo.t:iut.lii (cu atropirri,, cu rnodinX, cocainii, sulfutir, (l(' r,rrrfrrrrr,, r ) rir .!lri,.i/(rlostnarceXi,(e se pot flolda cu hipo- s:ru ltltostrtii
| | rl l l ,l l "r il

""""ir ;j if 'rii.'# fil,.rdsT H' .#. i: J,T,ii ii ll'i; iii;, .t . "i'.]t-i"i# j) sl;il,r'i.dupl, intorvenfii rvellrr o,orruJgrcato po etajul supeiior iazal qi pe sin ohirurgicalo po
nrrr.i rr) fiuli ; ; l() diverso dorogld,ri dorssH,ri respiratorii. resDiratorii.
produse prin aleetarea neuronilor ollaotivi gi a . 2:1,2, Disosmii ollnctivo. ?.1.2.1:.Dieosmia (anosmi a, hiposmia gi eaentualparovnio), ituttalowd, brutal y.i astaJi9 un ilaturAld, Jie'ile obicei bilaterald,'ie nrtgr,r:lrrlt rrill.oi r,r'rrlrr lr,tor.!iuni: ltl

pozo pozo (r:ol rn&l (oot mir,i &desea mir,i &desea rdectato); inJectate) : cl) infectato); d) deviarii de;viatii do de Bept scrt: i e) c't rinite rinifa'c.iacuto devialii rlo l,llzo (t:ol orouitlrl do divorse naturi I f). ozen*.; g) reactii alergice uazalo; h) tum

ryi hiJrosrnlirespiratorii (unilaterale sau bilatralo) provoctto ale rori,at|, e ra. impioclici accesul curentului respirator-la zona olfactivtr l,) rtonozoii sinoohiinaza,le;b) hipertrofii ale cornotolornazaloi o)

:' | 'I' l)ivt:flttiu (unosmia, hiposm,iaFi eaenlual parosmia) cu,'inut : lntt' ltrti rt prr4tnwit:d. ridicii ulrrlitoarr:lc problomo ct'io-po,togonioo lll 'l'trll'tt,trt ,l.f,rt'titt ola-ziw ,,fiaiologice" po&tc , Sunescenla 6it ror,llrr,rr, lrrlr" r'lllr( (i$, i'ot|8('(ntivirprocoselor' fllnolico alo neuronilol olfa,o" lf vf ;l rrlr lrrrrlriurrilor rru,slom. Unele std'ri, Jiziologicelo femai (graoiili.uneo porturbtrr'i ln perccplia, milosurilor'. Itlrt ttun,,ftu::tl / rrrrlleneirzii, Fh I lrrnrttri, rlr, l)il(li, hi;xrrosntiir din primul tlimostru de gravidittttrl l,tllbull lrlpruurirrrlirr rr,lrloik,ir, 1i al l,rcilll trimcstru, cu roverBibilita,totu l{tlhr| ||ur(,1lr,r ollitrrtivl dtrprinrrqtr.nr, homopnl,iilo ff) l,nr,ll luli lynualt (r, (liab(ll,ul, ur'('mia,pa,ludiBInul, r)ouxmii c{,ilor olftrcl,ivo,pl'in (liYortt(, lIlr,]llr, lr,l/r'r.rriiq,u,.)1xrl,af,r'ct{t, r,rrrr.lltrt i Bllli(.icJlicl:r l,(1, lrr,r,r||rlxn||', Iil iclr f i) '/'r,,r rrv, llnrralt tatt, lrx,c&r.'ntorlilru, $l[l,ulnifinlul, llr,bngilnrul, n.rginl,, 0lonlrfl (lo zlhat, *lIrrltlIr, i(x I Ir, lt|r,nl(]lul,r'Itrldn , ritr'l|1ul(1(] rtrllurx ilr\ r.rflrrr, llrlirirr(,rr lor'irlil rlc solutii hi;roltonictr (clt.t'u sr',1lir. t:11 |lllr,l|lrI r lllr ollirot ir'i). ll

.11 | I t,l t ,' , r' .l ltr i r' " ' l l ruttt,tl i ttnt ( lxt zr t 'lo, I t 'lr lt lllLt l, t t t t t r t t - lt ilxt r r u, t tio- t t n'ebt 'aht )rl tttrl trr Ii t,t' ). | ,,| l rl ' l ' | ,r rIr(' trc| IIt At t r int im , - r lr ' lt ikli1, r lis1t lut in l 1 t j " , 1t,nti t,nrl r' tti .Ia k: ; i r nt t it t in''t lt r t '1 it : i ( r ll hiDo- - sil'llil'lloil , t lr , 1t r , 1ic ,tl r' t,, r1,rttl ,rl t" ,' rrt,' i i i sttnl c: r zil gt t t il; ill ( Alvoolr ', ,,, ,,,,,,,,, ,, ,,t , ti z,,ttno ir lt t t t l) qi st : r nr t t lr lt r ir r t a, nf ilisr r l ' ,i ,
lll , I l \l l l l l '.r, l l l {i l )).

trilltcratil. S-aardtatastletlerseniqi is?ej;;, degi ant in rireningiormer;.1;,rul;i "biffi, iitactiv, in ;:,i':1:] liii:.1:il .:"T-1-q'iolippr z|'r(.rx|||lrlvu,)r'it,cerStii locale "iii; nesemnificrti""'iri"itiil iirofla mucc ::l::l ll:,:ci'l,rl,1.l,l lli unei 9"qrg rr;rzrl' r,lt:.)rrkrcit; leziuni cerebrale
optici,, Deci, anosrnia'prerl .tumola $i nrltir j.rr u orolusivii, o parte, qi coincizind cu alie'se;ne tumo _de :rlr' (| lt)irit (f vil|ra,r'e diagnostici'in meningioa-"rc ofircli"". A rrrrv 1l;1111111 de arteri, ca?otidd intein-d,, osteomul frontal, giotrtttl sulrrrsr'lirr,ijDmorilc sttlltilsclitt. l.lr{'rr,r||l tumorile r'la de ,r.r'in;. adpd, mi.; micd ,lj cle sfenoiA si unele tumori "i^;:ri;,;:^'^ rlf ) rrrlf l. l.l ln)L (t(,Lermina tulburdrt-unilaleraleale mirosului, cu -. deoset

:rrkrsoir bollavul se prezinti, Ia medic aor" .to""isau se il rifilr'i, cofi ce,aqi_tulburirile ocolare *sociat!;;;;ifi "i"dliur ifii*roi, , ou rk'.jrr, l)r:.rrrrrllc.ori, cin<Icstc recunoscuti, .1"
dcville sesizabili,doar atunCi cind este bilatr

,,,( N,H r(. i .i,u lbu;x;i, ti"t-iii^ rifi t li,ii?':ri:"if ff,.f T1,,T*1ilT%11

p;;i;;t]-, Ja'este atritr

poale insoliun sinaroi" F;;;l{";;;d;;';;;ii,fi :i:,::l1ll1l,t..lll],'l,t:i: ir(fr.r'rf r pl t t,c cu cu atrofia

acoroa ci, ;i it;.;,,';r;i se* l:,rtir, uv!.ritrj. (Ars.ni 5i cohb., .19?J).' ;";;;i; d]J"rlrnn,oe '

r:rlus,.t'.r'aniofaringioimele, -jt?.,1"g[oambte;;"r"r;i-;fi1" "on "i"ontJi jumoriie gtioamaeEentrale .r" rol"i"t pragur t ::)-1;li,lil,?"9"_:,-11 ri"lmin:i rionnalmultd,vreme,ir" ;;;;'.;;hJta ,l"ll,Jg t, estu rare Inl,iluitri,1,lnliv. .h rr,prorpc o treime'din ;-;;l;gr";;;il aripii mici rli.rroirhtlui,
r{o pt'orlucc tnrUrl so pl'o(Illeo (, crc}l,oro in-itria,lo crcgtoro a prag"utul. pragului. olfactiv, olfacnv. resnec res r i [(r(]{rrl r'l |:I r1r ir,rrlrrsr.lii .llrrr.l.ivrr Fi rl{.st:rl rlc I irziu sr,insbal,ltiiirrt iJrsilnl'rrriuhL r,urrrorii(ltisrrr, lr)fir).'Arsrni r'i ,r,riiii. ir.9i]lj-rorl,r,rrl,z{,
l"rt.. '

sibi.tatel ::,ll:il,: lgE:,1i-rrtolie.(Arseni p.l, irrlilrri s. in meningioame bffactivJ giganiq ql d" in "ri6'r" ""ii"a expansivZ I !i in iiO_"oc"rariic" l:::: lllll,-itt t umori hilofizare jArsen.i qi iota'b,-1'erz).-iiu-u,i'i''au.i, -""e ur :::i.T::lll: iillill"Jl,lie:lii I anosmiei precoce y:: in cursulmeningioamelor :ll.:1.,.':' i":.i::-?lli iltrlorior, in vreme ce aceastae-st" *ai u"ri" iffia1i oe cetre it -u1t rruruilro"iif l:liillj,, .":emptu .neorgmaliunte "fr' ii nr"

corab., isii,lsd)."-;;rmii

lll l trl l ,rrtrrri Trsi l ti t:a nt vnlzt r , llsilt r r zt r ' Anosr ni: l isl'cIioli, t lr r . pilt lii, " c 4in4 bolir a'r t r lt r i sil r r t ir oa's. ilr nt t t t iit 't r As1'li'1, ' ,, i i ,,' 1,' ,r,, ,r' l rrrrri bi rt ' ", kr r|| r,r,l,r, ,l, r 1'r |z ir rl ri Rl lt,rltl nazo-lacrirnnl (pl'in stimultrtn' trigtrtntltlttltti.t lkl it i I r r t 'a' liicr it t t t lcr yi r nir osul, ,l tr, ,rrl ,, l i rrl :, i l i ttrrri ri ), lur lecr noa, , st c qi : 11) 77) (,,\r' soni co1ab. , r rl { .trl ri li r l .rl r' ' txtrlttrttt'l ud'i'tr(t. cura intereseazd'ratlialiile ^olf l \l lttttt t'lr l)t t)11'!)o .8tt'11' nir r t ot lr r 'l'r i inso{'it o nu oi; t l') t r aur nat ism e r:rrcl l tl i l e, rrl l r| , i l trrrrr,rrr, - sinl. irr crtzurile de kviuni llill,t'cI illo, hlttttttrtrtt-trxplitrlt'ltil tl tt rrl'' ,' ,,,,,, ,1,, 't ,,,, , ,,, ,, , jiilol intracu eblale (Alscni qi colil'b', l1)?7) Itt .rtstt t lr t lt t ' t t t lit t t ibilat cr alo, st l llt t llt c t lt ) r ) 's1'l[ i'ir , i ' r,' r' r' rl :rl ,' trtl sr r , lL i i i r" , ' I lt ir l) ,,i ,,,r, ,, ' , rrrl r(rr ,,l l l roi i vtr qi, dc ur ul1, cr lr i, lcnom cnc do, t ll! {l}ozio il t\r,, rrr .r l ol rl b., 1 977) ' "lllt clplcitir,{ii olll'ctivc) sc i'r.tl'illrclkrtl|slttl l,l l. llll,'r'tl"rrri (or'o$tercil, la subcr , 1. 2. 1. 2. ' c1- oxc. . p[ ; iit 'it 'f r xr f it t t t il't tl t, r.i r,, ,t,i l rrtri l . rri rri niit e , , Hiper osm il por r . ' si. r cllizt 'zr '. r r lr {{'t i r ' [ or 'r r r il r,,.' , , l ,,rrl rozr') . i l " rf,r' ,," l , l ,1, ,,t,, tr,,' . r i "t . lodit ) t i", r r r ( ' so illLillr c: l{' lll ll( 'lllir sl. lll( l' ;' ,fr' r "ll I' t i ,,,,,, ,,, , .,r 1,,l N rt| i l ri i ' in'cur sul l1r sS, t ur ilor gr avit lit xl, l'l t r ovt r 4}t '{i llll ' r tiit ' si' pr r r t l. llsr ) ci: t cll ai t,, ,,,' ,, t,' l r\r1r ..rIrItrt| | :|I i. Alt ( 'u1i, ll ipet 'ost l r ig( 'lr r ir r r r Jir lr it r lr ililr t ic (.rr li. n, nlcuu r Jo hipr . r r . r t i ,' ,,i u,r' ,,1, ,r rr.rr.;rl r. 1\i l l l ?Ii ). l l l Il t l t Il \| tt.,, rrcrr, lt t t t lt olo l r. trr,l Ii i rr lihr it r : qi ir r ur r elc cazur i do opil( , , psio, l l l rrl rU r lullll) l i ( r 'l{' : ll' llllt , r t lt br Ll. dt . , I ir zr . lt ' ir r , , , r,tl .l )t : r lr . , r:r| | ;,, | | || || | | , ,, | | I , ,, it r un. lt r slit 'r i in- m ig- ur t o r yi i ,tntu, ,,, l rrl rr,rl r.,i rl i srrr,i rr piu, , lizi. gr r olalll,

1{)52)' 1$75; ll'isot'' i1)7?;l\lilorycscu, ri ,,,trrir., iiir,ili" ,,\i,,r'rrr

lrit,ilrrtttlt,l,r' lf I l, I'r||.orrrriilr. rirrl, rlisosrnii 0i|-0 cuttstittt lu irtl,erplotit,t


t l l l r l r l l r , l l l l l l 'l vi tr i :l l r i l tr ' l tr t'i l l r l r l r l 'r l fl r ti i l {) l r ti tr t l i l u l r ' I l t , t t r I r r r | 'r t r {r 'l l ' t l r r r t p l tl i l i l i l r : r l :tto g t'tl r 'l i r t'r r r r l csl r ' ;i to p ttg t'l r l i txr ; l t l r r r l r , t ' r l , l , r ', 'r , , , ' t 'r , t 'i l i l i i 1 i tt' nt'itttttrri'l,lt': timTtlii ,t t I I l'rtttttntiilr lnttrtlt, nt d,otul'tt'flIrur l) )ll lllr,,. ll tlr' Ir,l ', , r r r | / r f t t l t 't l i t \ ': g t'r r vi tl i l :t'l c. sl i l r i r l tl l ttr ttttr ttl t'j 1 l l ( r vl o u ( '; l ) si l l o '( \; t t t t t t t t t , l t:ti h i t ll,,lt " t r l t I t | i i . r r r t l l l t r r ' 1 i I 1, r r n o t' tttu l i u tu tt:ttl r : ( I r t r I i 1ri t i t t i i , l l l !1 r r l 'l l l l 'i \ u l n i u i t t l ti t'i i l r t , 't t t t u l r;t rlr rrttll llt").

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ll.l.5. Ilalucinaliile ;i iluziile olfaetive paroxistiee

,,,,,,,!,:,1,,,0;o;,fl{tffi ?lffi&:"\':2i1.-peroeperea.unorcu.rodsubir

sintrorme decrize e1r'eprico J;1;''.f iii';,?':gi.uJ,"'1,.y:ioz rr.r',', , ti,,., r rtr.'r i:eu(a.t io e,tr*i"i i i,i,, r-r'r:" :i'uiJr-. .f"ii iiH,f r:; "G'td t9Z6). Reprezinrd. j, ;i r.otab., "#rezulta[ui . :..::ll:i"',.' ior"a"",i"i ir'||:rtr.
:rt( . r , ( , t l, . x ului r rn r.i n a t (c ri z e u n c i n a te ),

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r'Iptrrlt{\ o(lol:trll,ji ln oursul

:l:lil,'lli:,,11:;l';:ii-':;ilil;,'i"'t#iT[ll1'"u0"",i11Y,;m:.yffil"il ru: ji tl;i "iT qil fl',,i?.fl i llr til* iti,s'#, #,# :1,i tiliibili: rgiliid

rura li:Ii: (,lll;, r "tc. :J': i i :ll,'#i; ::,f+ 1 "ff:T,'* Il:i'iil' ,11i;il;ti,i.'i;i''I:;.fff; #.it;;'";il:';;'ffi"f,1,",iii'161i,[ii;)r

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{t'.'rl)$ r,: rrr{,r,,,'gimioi r-i.".-a" p"[,"g;,Jfi ;*; .;i:;h#","r",ryHr ;ilffi 'sT, ;tl :i,'i'

u,nainate ,,:::! ,.. ...,:,.!:.!!:,! . lriret,c. epilepuce carede Wr!ir|. Crizele unor mj 'itzil lrntt lx.l.(,(,p{,jin srrrrrdrrr':, rr/ir,,,rr'i{,r([ ,i J"-"j:"'il'.j?tS^fl*:llfot slrt iare tz- rloTo

lt r or ulr t r l r r t 'izoi t t t t t : int ll, t r t lr r t t l, t t llt t t r r lr t r xl hr,l tv l xrrrl ,o l .i i nkrorri i rl orrlr r i( r l, it r r it lot l0pt 't r xiu, t lot t , t t xit r l, t t , l, oslt , t t dot t uf or i tx r' rl rrl rr..n{ ' " rrryl ,i i nt' ti 11"Lr.' ,Ir| .rrrIrrr,r), ot,r{ r $rr pol, lr r so{i r yi r lo sint lt t ot no r lir t st t r r ll ot r lit r 9i , , r r , li(lo ltlt,Bl'itrlltit!, rlo sltliv:r,t'io, sitltltl,tlttttt viutlrtrttl,otrtrt,l,ixtrto ltlFltrrt." (rr,tt q*rtrlllri' r,ri/Hir,tt Iti, 1.002; l'olxlvioit tii collr,b., tnol,orii) ( I'rrssotttt,l v iscrrt'ocil, t it t upr t t xilnt d; iv f ioJ[ t lin c1[ r lt t i o{islilt l ttl rt l ,l rl o i rrrl xrhr,trLxi i rr r {, inr r t t r llt ilnt r lo rtilt aol, ivr r r 1igt t sLlt l; ivc( [ 'r t ssou: r r t t ,11102) , rr * nn. i ,.r,' rl rr IrrrItrci tur,t,i liilrl, rl,, rrrrr,rrrrrrrrrrr, , rl tullgt'ott,ltilo,txrhr tttluitr t;ipuri tlo ttxprcsii otil;ico strnit t oxpr csill lor ( Pr lpovir r it t qi lllt sr r t t ' 19t 10) rrrrt,rl r ;r.trrrrrlH ri sr. rurtttl l lt i, ozo rtd rrrr rrrl.rrrr,rl(l rslrrI{rn{ll, ri1,,,lillsl" porcopfio ol{llcl,ivir,polr,lo I'i itrso{,illi', psilt t t - sllnzot 'iit lt llr r r i lit lg hr l'r 'i l r ,,,1 ,1,, rrrrrru| rrr:rl ,:i;i rlo: r , lt o t ipt t t ir lo r n: r , n l tl r Ir,Irr' rrr:rIor (r i zrr:r1., : lur lit , ivc, Lr , t r ir inl, ico,sonr cst ozico) . I ln0lt r r 't izr r l i rr i rrso{ rit ot lo , , st t nzr r t ; ii"soxt t llo, r nolgit xI pinll, llr o. lr r irrl i ,r,l rr,, p,rl . rr:i , !rl r t' ,ri rl i i (r\.j ttti rrgttttut l f i lt la, nc, ll) G l. ) . I 'lt ssouant ( l9t i2) N, PI '{{iizir l, r t ir nit osl, r ililol clinim llt r , , clizt li t llf lt cl; ivr r ": rl rrrr ,l rl ' ri rrr rrrrrr| osi | l l t oil, l ,rh,r l , r,, 1r(r' ol l rtcl ,i vi , ( hillt t cint 't ir t ' ol! r r r r l, ivii) L, st lr nt r t lo vis" sr l, t tt lr , r11,1' S rr, l rvl tt t snt ipol; t zr t , ct i t t , t t lt olf : r , cl; ivii t lo Ll t lt r lt t t l, t t l r,,,rr,rl rzr,rr.. rrrr' ' rrl l rl ,o | tr.t ' r' ' l rr l i i d eclilnqllt il t l0, , t illencof alul olf a, cl; ivt ', t lllr t t ( r sl't r propir if onn ( ut r cus) , cl, r o t : st o lt r glt t . lt rI ct lt r lt l; or ii l ,l " ' .,,' l L' 1.rl l rror' l ,rrxrrl ( . 1[ r r cl] cr r n li ool&l) . r 1952; ( iloor r lll( il; tr,rtl ' rt,r ;' rrrr l rrrl l rrrl ol l rr , r . lbiv r i s( \ I q' ,,,,rnri , tl tt;:;. l rr H ch ir nl) , r n*r lif ( ) st i, t 'ilc cor r t lt loxt r psihosor r zor ir|( rlr,,l,rrr, r''r ,rrlrrlri,('ll propa,garotl d tlsciilcir,r'iilil ,,tinontlol'lllttl nttolllttrl,iv" | | r| ;r,l ,r,rIrr,,rrrt toprozi n t ii un vor it ilbil , , cl'oior t iut r t t cof l ir l", t r ot r slil't t ii; (cl r pa,rt c r eccpt or ic) [ i ( lir I ct t r lllr ] lui At nt r t on ( cll lllt r i'o rl l t trr r r,' rl r rrl rrl ,rrs r-l r{ ,1" lr' I t ,rrrrl rl .rrl ;rl r.rr, sorrti ologicl a t t lizoLt r t t t t t t inlt t t , r osput t , iv it t lt iclt t olr , sliillo", t t | ,I i I I | | ,, | ,| | | I | , | ( r'il,i(x) ?sihosenzorilllc cu forttttnonul de "{ll(rarny , iolt t t 'lo r.rr rr,rrr, r | ' :| | | r,Irl Ini ()i i ,, , ilt r ocut uluit ', ct t r ca, cliilo t t r no! r yi t lt r i, r r I l rl r,rrl l , ;,,rr,' i rrl i cc i rl o ,,oonf lt iiDl, oit teului, st t pot inf clego f olt . t , t r lr ilt r r rlHi.it llrrr'nr r.rrtir, (lo contploxitatell func{iilor dtl intcgt':rrtl alc ,,tirttltttrtrlit Irrl l l rr, , ' | | r, I rr ' ' , rl sprrtrliv t lc r olul jucir , l; r lo I t ipoc: lr r t 1 li I or r nil( it t I t ilt t ' rr r,irrirnrv{tlntii lirnbicc in exprcsia tnto{ion:llii, [i lrl rrttlo(l{} r r r rr 'rl,i rrr:rr rl rr tt t om ot ie, in 1ix: lr ca, t lalt lot r nnt r zir lt r ,in r r r gllt l rl trrr" rrrr.IrrrrIrrrrr.IoI nlr|| tli,r v(.glro tlt: somn, procurn Di in lcgl:r,rcJ'viscorall qi soxualil, rii t!,{ 'lr, l l ' or' ,r' rr,,r' t, tl rr;' -t i (l l ' )" r' , l06l; O r r , dillt t or ) i colr b. , 1962; St 'gcr qi colillt . , l l tl tt 1 1,,1' ,' rrl i rr ri i crrl rr , ll. ,1{) ?8) . rizoll'zi' prin ' I tt ,l t't it! r lltilc\tl,ioa ilttzi,on,ulc oL.Jacti'Da Bn clr.N,cl,e t lt lt t t liir calt t nt lulonillf i, N,( l( , t '' o r,l l rrr' l rvrr :rl l rrntt t . lt t l st t ger t r it zt l, l + ' rr,,,11, Ui l rl rl rrt ,rl l rr, l rr rpr.r' i fi c nlr t t t lin vt r r inii't at t , puf , lnd t aco par t o dit l <r t izr t , tl l , l (17i3) l l fl ,l l ' rl ,l (l l rrtrtrr tt |', I tttir'lr tpiloptice o$actitse ,,telflcna" ((lnstllut, 19?ii) sinl, orizrr yttitt rt'ltlitllrotl urrui 8t'irnul rllltctiv, tjrsp(to1,iv xfll|r1ltr r, rIr.r'Irrrrrlr|,rr 1tl'in' r t ilzllkr . Act r st t t olizo Blnl;r t xt r or n t lo r lo( M ot lis, t; frfrr,r. rl r' rrl ,;rl rrrrrcoux ci l l l l l I | ' ,,Ir' r' i l rrt ri i rxrl rrl r , , ll) 70; Sct vil r yl ur llt lt . , 1002i St 'oiulr l9( ilJ Fl thl l ,l r, ,\rrrr.rrr11i (xrl l l, l) . , ll) Tu) . ibttli a't (,,r1o inflttcrrl'ri'" ' I ft h Ntrr,lrtn'ul hnl'u,oirtuhr oronio ,y'la n,l,r rqrl ,rl , ' r( (l rrr\" ) (l ti sr' ,r, l{}li9) sr c: tt 'ltr llt tr izt r t lz; I pr it t l'r - o gl, llr ot lolit 'ir t r l'ii 'sl0 r 'onsl, ilt ti l, r l r li|l olt r r r t r r nf irlt illt t oit t it l'ot 'ii l l .tl t,rl t, ri , ,r. r' rl l r,i l (,nr1r l, iorr1, t 'pir ' olt t lt r Lr l lt lllt t t : it lilkr r ii, lt olt t t lvii rrl l !i r,l l rr, l rr l r,r'r' r'i l i r' , rr,xplr iiv it t r t '[ it , t :r {llll ll( {'l( 't l l rl t,utl l r' ;t l rrrr,rl rrl rrri l o$| lt ilo, lt t t t t t xl ; t r t t r : ir1i t r t t lt t olit r t t lozilt t , lo, t lr ' r l r,r rrl l ot t 1i rrrrr Ittl tl l , , ; r . t gt , r r t t I it r ". ,,rxl 'il"
I It

14

lr lr l i( 'ilr li'll rrrvcl l tl rl c i trl l rrtl i r, vi rsrrhr tr r , lt t t it 't t r ,it t t t clt ', I it t ll, lit r 'I t ilt llt I t I l, l rr.rrrl u ,i rrfi trrl ronrttl l xxl tl i olm r t r lr l, r olr t t llr ir t '( t t r r lilit o; t i'ilr i't 'r 'lr olr t t llt lt l'I ) . dr po. Tt ilo A J I\pi l i tu. (si ttrl totttrtl t r t lt r iu jr t , r t lohr t lharsuu sindr ont . r t l. (r'ttt.lrinu.rtsulnrc'u,li) (llintrr, l115!; l\'llttrolcxrrtt, ll)fil{1 rliavrrostie n, ttili ttl,t1||,i0/ousti, rdinic' lopogruric si .tiopatogenic ,,,,',,i;;;l'rli;ll$;rlt' Hilu l)illlrfr'lllt si rrrrilizcltzi't,tta,t"r lrtlbtrrtit"i, lltilr lrzitr 1u,:rlrrfi t.ttrilitt,tuirl?i rrrl " i trl l urrtatori j < l e tu,vtill, in1t , r 's1, if ial1' it t xllr hullr lr r 'li, : r t ) Ar r t t ilit lt 'ir uizuote r r:rrrrrl sr:ade in cil, cva zilt : , ut t ilai. t 'lr t l, slt t l lr illt ii totdoaruta l ap it l, lt llt al, sepot exprimain urmatoarete l.r;rl (cga,l sau jnegal), pini lr o drarnntici arntntrozil; ll) (lirrrprrl vizrrrrl '11llll{ffiJi,Jcaititlii lll .4nbliopio lepl.czjntdtlimjnuarer acuitrilii trtt st ttlnltttt,' , rir. rlrr ollicei ingustat concentric, dar uncori tloar sectolial 1si vizurle. ll\ Cecitalea silsiu amauroza reDrezintd, nicrrl,,roo rnnoti ., l,lrirrt ccntlalc), vedelea macular'[ liind mai rcspectati,; o) ilitttItll rrtrr rrr:rlic cste foarte a terat (cu moclificS,ri ale cir,rpulilor ct'ttmlftir,tr,lltt st,,r lrilatoal[ (6i in accepliuneia, l,,irrr{f pontru culori, cu discromatopsii qi chiar acronliltopsitr I'olrtli); c*orectEiinli*iX,-piiiiizt;ne' ce.nt.",u ,lr \rlrrptarea la intuneric este loarte deficitari I e) Adcscn lo1'oltsii '1i tltr ..io D) Ilemerabpia reprezinti iliminualea acuitelii , rr ll rrtilci,rile globilor cculari I f) Pronunlat edern pa,pila'r, prrpilrr,Iiittrl *, l.l spl:c Seara. r,,.rr,,, lrrlblre, tumefiat5, cu conturuli foarte qtelse, cu sll'ii (r1| I ' I I Ii t'I t l i | |r{' "irort" ,,.rrrl,ii-rozate. Manifesti,rile edematoase peripapiltlle se itrt'itttl ltrr zott, ,r;rri rrLr cimpului oftalmoscopic, r'ealizind aspectul rlc ,,ntrlttorrrtirtilri,". invizibilc ( llisr r t , l1) l': l; ' ,,rrr1i rrJl cpapi l ei deveni nd , in accst c sit ualii, .,,.itri1i, {ininelseama indeos?binc.rmai.oarete-;i.;l,iii, iiJpiltir",i \1. n()l (' s(i u, 1958; D uke E l d el $i Sco1, t ,19?1) ; g) Yelele ; i t ,II I t i IIt tr ' It ' st t r l r.rrul al fundului de ochi gi pi,strarea t,r.rri r. rl i htate qi si nuoase , ar t er ele slnt inecat e in et lcm ul lt t r t sir '1 lt ) lt r r"tf"iofui p'r!i"ar la tuminri. , i l,,:rr'('l(i papilare $i pedpapilale se obscrr''Xhemoragii si ctstttlrtlt', r'l'r'tt ... l') !):l!r"*,atoysja_peytyyalb negru fi tentru iulori reprezintri tl ,,l i rsl l ccte de trombozd velt la, s: i cu zone vast e t lc t 't lt r t t t llt 't t t t iI r r I lil t t t in-considerare,'inirucit l aceasia poaresd, :l:,1l,,,1o'1'"]T3"jlrlt-,*:.ll?1 cr,rr,rli o scrio de lezinni ale chiasmei l rrrrrl :rcr.storl ezi uni ; i ) C o af e, ct ar eavit r osult i se po: ll, o r ( r lr lizr lilr l) r r lt ilil, r ' $ rtlttl;r lrr, lrlii (,\,[anolescu,1958) ; j) fn forma de ner-r'i1,L opticil trtlt'tttrtlortsri i!.2.1.1. Amb_Iiop.iile :!./,,.1.1. "in "ail'* Amblioniile si,amaurozele am.turncplo "pti"b n.alra <; a,,t,-..,]*^ acute si sul.tacute ;i, se iatilnesc in nlr l ir r ( cit at r r cllr r l t le Riscr ', . t 95! ) rrl r:rl rrnrr.l i cul ari dc Rcnar d descri si i , ', i rors(| ir1(:(i1i1tni, de diverse etiotogii qi cu vdriate tocatizXri pe clitc t 1c , , nr Lcir t cii'" lN' it t lt 'r t t lr t ct r t lr r ilspect o rnasi vi , tumcfi clc, cu ;,ri rrrrl i :.4.2.l.l.1. AJecJiunile in lamatorii ale nerl)I.tlui, r I rLri,rr'il canalului op1,ic. wtic l. /. l. l. Perinct:ritele,optice (nearitele :!.:4. ii r lio1ul,, lrr lrr!r unui tablou dc papilit[ trebuio sii plecizitrrl .lut,lrtt rr.lrlczirriiio irrIllLrnl.r,t,io Drim:rri, a, tecilor nprl qi kx, r t L' r r lt t l. r t r : inlcc( ii r ninulioase: a. ) //ri r i nvesti ga.{ ,i i si si em at r icc ,, l )r' i n rlrr olrir,ci,r,xtcrrsicirrlui pr.oces inflamatrol Ae fa'r"eilinld"'Ja" .i" fa r rr,l ,ri ,i l l i te, coroi di t, pl i igi per f or at e inf cct at e alc glt t lr t t lt t i oct t i: r t ) ; ( l') rrrrzii,o (anterioare, sfenoitialc qi ctmoitlale postcrirllurr) I tr) rrlirr'littrrr :ii]'ll:1,',;.1":i:,1^'j;'l:1.'.",':'si:l_::t11i.obi$nuilisinttacteitiepiugenc r lr r \ ul r rru l ,rr tl l l,r o r, i, r lc it rc l i n g i taa-SUpUrJlivi cprr.bro_spin ir illlii, illl in nn|lrngrl alri i rrrII:rrrrrri ol i ial e urechi i me dii; t l) f ocar e dent ar e I c) ost oit t r I l) r r , lr r ii", r lr r t, -di fuzi uni l(|i.| o u; r Jr rrl sr r l ( l) r r k c ll) (t,ut({r scn t. 19?1). lrjl(lcr ldcr s 1 i l||l|st. Sc ol-tt. fir Scott, l 9 7 l ). Este E s l c vorba v o rb a de ainzltfi in li trl, ; r1) inlrc!,ii generale (scarlatinl, variol[, folrrl'i,liloirlii, rlill'r'r ir', gli;rrr. lrrl rr;rtir' :r|. rrrrr rr'.rrcningite bazaie bacierie.ne1inc1u-sii iaclarc S I ,,,Lrri rl i i -un, ti fos exantema t ic et c. ) ; h) papilit c lL, ll1( r $ilt l f it ll) ir ( llll( ,I t i, l 'rniiai,ato"ti i'.1,):.,.'.',ii,'flll lil)..1::ll::t sau ale, altor p"occs" rt' :rrr,rr, ,5j i n scl eroz:l i n plici it llusr 'lu ocult t r ', it L lix: nillgo- cll( x llllil( : l.l:1,',','f,':1,1 1 ,il:]:l:rl:lij:_"1,"T: sinuzjie sfenoidar" i,'alarc,se r.r. r1 rrrltrr{ii virotice ncurot'ropc (o{tralmonculoln itrlilrii, lrollrt lrti l)rrvirr; ; ::'l: ;:1,r, I ll r'tinicc: perinevrita jl;:1,:1: , r' , r' l rrl otni c-l i to demi el i ni za nt c; I t er pcs zost e: 'I cr r cr ialil, o; I t t t 't t iI t I '; iicr t r , t t lt ' l]l,i::,..1:llr, , , 1rlr l ri p rrr.rr llt t ll' 1, . "pii.a"".iiaJii"#c;ilr;I ,i , ,l i v| ' i so nai uri ). |)iIr11rrosl,icrrJ trsto orientat de: contextul general lil N c1)ritct, apticd, refrahulhard &clttii' :tan' stthur"utii (t;lndnntttrl 7r'slt /,,r/ s{ , < uracteri zeaaX , i Ir plincipilr , sPt r l t lt r osclr it t r t lt l piLlt ikrt li, t 'r 'illt -irn"eor, / pollrurli r"rre cx_plic:iambliopia * $i cu la*traiua . pri n * a l i ps:l sa r r r I isclef ia, m or lif icii, r ilol t t ] t ir xl, ivc r r llr t lt r t t r st r r t ved rl rrrl b:rri l , l rrri ,rcrrllrr,|r,). r.rrtr':rL.)lrr r,rz,rl cu,zlrlriirprr ili"i qi dispari,tiei a vecleiii centiale se lnsiJeaza o ti-;-;.d.;ii | prczo nl'll ilr alilor l, t t lbut i i vizt t lt Lr lt t t it '{iot I I t hr . rrr pri n i tchi mb l ' r( a-eclematui pupitr" ;"riuiloio" q, ;i consecin{d !txtrioristici :lllj,,.ll.',11:1, f,ln I clinil : lt) l)cl)Ii, l)l'ujr(f, itt c,ilcvu, ziL' trrrlizitttitt tlr' ,, ('l' llr'{. I it l)j' J o . " ,l l r.r,r' r, rl l l rnati c:i a tcrti 1 t if ii vizr t lt lt r , pir r ii' l: l ct 't t ilr t 'lr t(rt t t t t r t t t t lt zii) t r ot t t pt r tcoplit r i I t lt nilt lt it . st '; lr ) ilt r it r lr r t 'r 'lr lt r r t t ilir {ir 1,1l :i , cl ri l rl ctt rl i sprtri {,i ir , r 'sr t , trt ir r sr l{, i1ii r ri rr:rl ,rci i { ,r pt' ouxl tt,l i i si t lir lt lgii or lr ilt lr t r slt lt lt r , t iot 'lt ilir , t r ', ..r'rr.1;rl. neyritc optice) iealizeaa:i.tabtorii v1\ r ' lr 'r il r,r' l rrl (' sl l ,l r tl t' t,l l rtql l l ri l o l t lr t i r iililo gk r ilol t t ( lt llllr i ; r i) iJ( r ai( l'll( 'r t1e scciiuJ "ti"i""-,iitrirJ"f"Si." afecrdrii vu,ur ;t;;;'fr up0rc: pc pl.rma . i Ll rl i ,r,rIl .i { (i i l rfitrtrtti t """.*. *,:.:i." l i col o t t t t t ct t lt 'i llt , t t r r t t i t lit r t t , t lsit t t li, t t t t lr lt i 31r ; 1lt t t l, li:::f:.lll,f13"ll: il.i,", por I ".r-""l"i cl.recuprinde ptpila .rr|r .irrrl:llrrrllrarJ, n(.r.1 opii(1 ul | | Jr' l ro,rl (f :rl ]ol rrrri i trl rr' { r , int llt t l vizt t lll ( lt 't t t t t t t t 't t t lc , , t t I l't ill'i t t lt r r llt r l lrirr;iI:r'zuuartc i "i l vllsclor centratc atc t"ctrncrin lcrv (10_.LZ mln), realizindri-so ( r ll( \ siud l )l t| i r' | ,l LIll iLi i''r : oli, ll) 71) . llt r cr r l i t it r t I I ot t t t r I I '( 'I t ||ir | l r rrrr :rri rr!r' i )' Nrrl(,Jiol', i*xt,abuJbar, p4lilita sau sinrlrol.ul dri lrilpil. _ ( : r I r , r 'I I t t r , : r t it t lt l, gt t lt t i t t , tt ,l r,:rr. l rr.rri rrl rrrtl l t,i ; rl ) 1' t r cr r zt t t ilr . Fiit r 'r 1, , t l rr.vrilr;.i, .domz I.rrsii,ircrr1,l'l' srrusrrlliriltrfii; il' (r)r:r lx)r{rrt,r', r.rr.olrrrlrr:'ii, ( ) llt l'l"i) , ilt lllt lllr zli illr lillll! ) zll lolll l \'lt t t r t t lt $( ' st 't t , irrl,itrsr,i rlrrI l ,,l ( vl i l i i | | i rtIri | r,Ii .i i ' '

2,!. l'l1I)lnXllA l,l,)Rlri(]llrr tr-l

(NlillvUt, ot,1,l0)

"i'#trXl:::iu^K:T:##,ffi:-ii"$:iilrTi,l":?Xr*,J ,,,'',,iJrv'ffi tlllLLi,'#'ii?'ifdi""lffi "'f"""11?Y1 i?: {?::;,;,i:!:,"'i##ii

#,l:'tiH" i'_lTi,$"",i,",1 r: I l'lr!{,?i'[]i,'i1iii."1iL,slf se j:311", se Lci' oiieiene#iea tap ae ]jlj,,lltu'l]:l;.,o:11 llry:fant "':?n

"fiff, ,1.,,,ir1.,1i,!.1.,,fl"'l:.it'i, J"i,*" -l'iTl,:*gx,"ll,';ji,:l*$"1

l6

l't

l)l.lfl,,ll

r''I'l

,,,l.

irrol'L,\ir! l)'J)illt,l.ri ryi rnitl.irr,zrl (rr.v.ll,,

r.rrl,r'l'rlllnritr
, l t r r l , ,, r t r rr t , . I r i . r r r .r 'r';r r ;:i i , r i . l ) ( ) l ,.tt.l l r l i l .i .r r l l ,i i ( i r l r r r l i ;r g tr ,si ,i . r i i l i r 'r ,l r '. t k r r ' l ', r l 'r t r t . r , . i r l l l , t'i i i r r r r r l l , .r t .i l i tr l 'r r l r .l r \,1 ,( i ( ,1 ,( r.H i l t,r , l l ,'i tv llBt ' ; t , ; r , 'r l r I t r l : r t'r l r i r ':t tl r l r l i tr g r r 0 sl l r ,, ( i r r i tr r l sr .r r r tl tr{l o t,ttl i ,l n ) l tr r ,L , l l l r t ', t r pllt.lll l 'r r l r r l : r r r r I r I r o Ir i r .i r .tl r r r r ;r i l l r ,tr s,l r r i i l .r r r l l ,z:r vl ,'{\t {x,l 't,i tl t. :l . 'l , r t t r l r r . r r r , I r r r r | . r l , r l r l r . , r .|l r 'r ||u l r r fl i r i l l r l Isl o l i r a r ,l ,0 r ,r l ,i r r s, .l ,r ,r r r ,Lsi lrl lrull

r r r r . r r l i r r rr r ', ( r ( . r r r \\r Ii r r ,,1 r r i .r ';.) h t l , , t r t " 'l 'r , l t r r .tttr x':r r t:r tt.i r r ,ttr ,ttr t ll,,j:l]1l,,",11::l:lll.1:.fii.,":1t,,;tlri;r1;,,,1'r,",,'',Liii,,i,,li'i,rii','r,,,r,ir,,r.rmrno rr.r'rrrrliL,r.rrllr un.',,,.,,,r,i,, ri,",i,],iiuir,',1*i'iili;ifi'i,,i;;;',;,i;i;lllir",l"'T.llll t r l t *'. , .r 1,rr, ..\tfilit, I r r r i .r i v r \1 .'t l |r ,r .i l ,i tl r i l :l r , v.r r r r r l i l l r i ,l r l l r l i r r i r r , .( .r .r . slrLl.rr rt,rLt,ir

t"mporatit, f'enrpo.a lrih t,i. it,ii.,,,;;;i' rt'i rr,llir,ro ,;;,,,,,.,,, rrn riisnraf nn rliscrot ,j1lf,;' (tt.s.'-ryi.Ashrvorrh, rt,'t,it,,. rsos,'oit*U'd;"ijor.," iir,r"" gi Scott, I n71).

. | o rl{'(x)lor.itr. | {' { || | )| I r Dlpih'1.1,, prr (lr. li1,_ rtr. ,,fricci obicei

;;i^1xrs.to|io.rl c) ; .e) Oftalinoneu"rpj:llte ft;;i;'t"ib;;;;; ty no". (ruieotd, virotic(. parolirtild or.ioiil'ur,c"ira"e :]ll,l Ii:l.l-,1 \':tlrorr.it,, zonil zoster, variceld,l--bacteriene "piau-i.;,
(diverse), riclettsiene qi (in special mataria, 'irip,a,no^*]r;r- qi;;Aiiiiloza) t,rr,l(.,,,{'irr(. ; s)

r.', lr,.rrr,,r'irAiil,, ilini,.llll{lr,r)itsrr rixl,irrsrr pr, irril.g ;ri Iilrr,l,rr Sll. ll:, l,:,1,, lllltl'rl r,lrrr,r,, lrrrir l:r 1x.r'rli,r'ir,, rl. lrlrr'u.rrl v.tr.Lrr,(.rr.lrr,rrrrri t,, irrlri
Fl i tl , l || t' ' t' rl rl r' )

ltt ll|'

I tltnlttlttnttlt ,

, 1,r1'rt.rr,, rrlri.r.i,,. ,,,.ii(l,.11.ir ini.tlirrti ,, ,,.,r,it,i1ii uii,,,,i,. l,ll,,l .r1,. r r1,, l , | | |lr'
l l l t ; O) .

ti o l t n l l

tl t

ttr r u l u i

o Jr ti r j l \r l ,

r u r l i zi r , ctl ctr r o ;r

'l'rrlrlrlrrikt clinice descriseanterior (vezi 2.2.1,.1.1.) pot fi rcalizate tlc t lli .lu,ckri:

I r.rlrnriloirrdirc<rlt :rk, rrerrulrri op(ic ilr Lratr uraI isrn rlt. r.tu rrio-rrrtbrrtle inehis0
I r' ' rrrrrrr' I r rr rrrrr: r r i rrrr iadilr *ir '( r r . r *r v ( u) r i( . st ' ir t t ir r t t r gait t r , r . ' 1r t . ,1, | ," ,, rl rrr l rrrr r r 'r lisr r r r . lr . r , r . lr r r i'r , r , r i. b'lr L, ir r . hir-ir , i, . l. It{t.l t' -r , ) L. r l, . , , 1ii, , , . , j rrrl r' , r,r,tt' ,t, I I 1 I 1 1 I I | 1 ; ; | ; ;1|t r si r r r r r i I *. avar r in sr , ingi. l [h.l ir r i; ir r r . s. r r r . r" r' L' rr' | i r{ r rrrr' ..l 5- r 0 it li, ir r nlxr r iir l ir r r r inr i. 'l, isr r r . r . r 'r '. 'i*r r . IH rr' ' r ,r,t, rri r.rl :r rr r . r Lt *r l, l . pr lir . , r t . r , v, l pollt , . I i <xr trtllr it r 'r 1. ,lr , z; t l, l S tl r' r' ,r t,,t:rt ir r oour i, , ilr ol, t , zi l ,rr cir . r r [ ii ulr r i lczir r r r r l ncr . r , r r lr r r l l fl ' ,' , ,,,1, 1," ',rr , .1,:r tl l l l l r .r.rrl urrl i r r r ir lr . ilr zlr , t r r r . l'|, i t r . , t t sglt suol oollt i( r t , vil, l, . rrrIrl ' l ,,rrrrol oi l ,' u l 0 zir r r r ilor ir r r lir '. olo , . r t r , r , vikr l 0pl, i. , i ir r l, r , r r . I r r r r lir .

inl,0nsmidriatice, iar reflexul fotomotor este atrotit. Nrur,,,u,tr1.1r,. oTtticedin barbitu. .alte_into,ri,calii 'aciri .(optgchin, f"iiix mas, 'etc.) t ilr.,., irl (lo. bromuri, injtoform, ialicilic, snli"itnti 'r ',.r,r.lrln, sini Irrr'tr' :r,u,rrri'itolrft! cu cele chininice, dal,oriti *u'""oirro"i'o. ;;;G;;i v;r.r.rrl:r.r.,. rrsrrpr.rr. cclrrlelor ionare din reiind ,i ,r"pau fiLruioa'n"uI _gangl v,r;u,r. (\frrrrrrlr.sr.t', t.Di8). N.europatid. opticd din intoiiealii iautd araenineld rmporr:)nle, cu evolufie spre amaurozi in citeva zile, ,i1]li'.,.r.,.,,r:,r..,1,,'l]],'(,1)u

chirrinii (in scopteiap_eltic sauabofiFj qi p"oauce amaul |r'r| iiir, :r,rrblir4rii, irrsolite;i de suiclitate,re_marcatd OulA ieqireatiin .trr,(';trrr'r,l,oirHli, rlo citeva Examenuloftalmologic arald,ciieva elo. 're, nouropatiitoxicu , asiecf rrnrrtr.rliti,r'rrrrl,irr,lo.tu,ff de alte isclemic aI rer^r,r.l,rrr.o cu paloarea F.O.; TACR^estemult crescut[. lllll''l i'', ,Iiliforme,. I'rrlril.hr sirrl,

(jilzaro ;;'i,r,' n(i r j n{,ir,r retrobulbar6r cu scotom initial centrL,l, "Ireyrltra" rrlrrrrrIri_rlrr o rrl,rnfiooptic:fi progresivi, cu intens?i, a papileir "*ouor"u t$2; Eiiazzoni, i6[f : 'lii],,i,jl:.1.,,,:11,1.s11""^o-3joas';,^{sf,annon, ;l:,1,:l'; lil,rr{i.rlrr l)1lrq-l!|lcr fi Scott, 19?i). o1tt.icd, chininicd apare in urma ingerilii cle dozo mari . -. N tu.r.oltutitr. (ci l.v;r grrrrrrc).rltr

l; [t,'r'rlrrt,rrr (|pli|t. loll,l r,lr rrrnlr t,j(t imrrtliirlc. lr)kr sirrl, hr,r.v0rrl'| -, Ir' '"rrlrr rtr rrrrrrr'.r(,;rs(f vrrIirr{iillt,it crr, gru,vilrrl{' trii,rli (xr rrslx,r.l ll,i,i,,,',"

,, r.rrrrrIr' rrr.lris. r'li. vitriui,ii,. fllrih r r'rrrt'' J)ur,ri rrur'rir1,ur ,,p,ur.i{i,,i ni,li ,,, rrl;rr. r,lc in il crLtttolii filllr,l,,r JxrlIi gnrllr,tc :

,rn,,,i'l,li'i",l,i"i,r;,iiil;;liil;llililii;lfi1'lilll;iillL l,'t,,r,r',r,,,r
l4llirt
r cllr r .,'t:'rrirr :,r,s,rrrr,,,r,'r,i :in','"i lillil,,lill;J,';i:i":i,,lii,;ii,,]::ljij'lij;l'1rNcor,"'|r'ii,, I . ip lr r . ur it , r r , , lr , , i,r r r r iI r r t clir I , , , r . iz, , t r lit l $l l l ttr rl ,' l rr,,rrrl l rrr.rI rl i r ) lr ti( . ir .r . lr 1) l, llll) : u. i t r , : r r r *vor sli. 1rr rrrrr| , I Ir ,1rrr, rrrri Hl. u lr ill, t or , ; r , lii, scr nir ni<lr . ir r zr i r r r lilr r ut lr r r lr <t ^,.,

:rrrr.rr{it.ziuirir,r' r,rr r-ri,tirit, vr;;,,;,i;ii 1r,rpil, ,,, rl..r :rs1).rr

r,r'r, 1,,,,, 'ij,ll,,,Il,'i,,1"1i,j,ljlili,1 ,d,,,,1' ,ill:ilill::,i'il ilxlillilii;l,ii;ili:",' rl t rl r.l t' .rt rl r. r.i rrrtr r t zr r : r l t lr .
l l Fri l | l | | l i | | l i .l trl t, rtrrri t t lr t

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\ | rrI I i I rrrI i Irr,Ir tlc. .lucl,ori etiopatogenici ai nevritelor optice dc noi (Popoviciu $i Pasou, 1980),pe t'r1r'r,ri\ r. rr lirsi sisl,rrrrur,tiz:tbi, :r Ir||rIr|.r'r|irs(| publictilc indeosebi sirtrlii slrr,listicc, de Dukc-lJkler SI Sco (r1rir):
ll l"ttt rt\i itt.lltuutl.ar.i. Lor:ali ,1i ai B.i[.C. .. a) Uveitc si I'etinite i l r ) lrrtrr'(i i ir r lr , r rr r llr ilr r r.c ; c ) ,\Io n i n g i te o to n i c e (i ndeosebi brci l ara gi lr , lri :r);rl l \ r ' r r lr r r oir lii,rr o p l o c h i i i s rn a ,l ,i c e (c u e x te n .si eantori orl ti , cu realrr:rr, r,lrr:rl rlr. rlvlil(l .jrrxl,l,liullrtre ,sipapilito) ; e) Sinuzite antedoaJe fit tr.ri,.r r,, rlr' ; l) 'l'()\oplltsruozir,;g) Tubelculoza, fic prin lropagare, directi/ rlr. Lr ri lrrclrrlilr vooirrc (proceso tbo intra-ocula,re, iridociclite, osteite etc,), lr,. rlr' lrr o rrrcrrirrgil,iitbo bl,ztli,, {tretermlnii,ferromenc de ne.t-r'iti, gi rI0 t)(.rrr,vr il;r oplicir,, clrirn dc pl.pilitd, (Sverdlick, 1964, citai de l)uke-Eklof rrr ll ,ri l, l!)7l). li,ll,rl\rli ljoitte dctermina un tuberculom Solitar masiv pr, p;r.prl;roplicii, crr rolliz:lreil urrui tablou de pseudogliom optic (cn simlrlr)nri , r ;riil rrriri s{)v(lro c1t cit i,uberculomrl se extinde ;i spre apexul ,'r'l)rlru ); lr) Nlvlil:r, ol)1,ici:i sifiliticd de obicei provinc de la o meninEitf r r :rrrrrrr.rri rrllr llr r r ' lr r lili lue ti c i i l , i n s ta d i n l s e c u n d r sau terti ar al l uesul uj . '\r1,.r.rr rlrislirrrL l:l lriirttrrrcn, cr'ncomitenti, a neryilol' oculomotoli, faciall r.r r.r,lrlco yr:rlilrrrlrrli. illtrlLnrii r.iltr rl c r*cdere sint yaliabile, ,te h u$oir,l.[ _ :rrrr| I r, rI rir, ;rirr'i lt rrrrrir,unrzi 1ofltli,. flalacl,eristice sin1, strimtorii,r.ile corr ' l c r Lt lrl l rrl r lir r r lr r r lr r i v izl l l l L p c n ttrr a l b fi l x rn t ru cr ori , precunr si s0o. l o rrr'1 , ((.rllir lr , s i/ s iul l )i u i l ro l )l l a l c . l )i i L g n o s l ,i c u l se bN zcazi i ,po dl i l (!l r i r I r: | | | rI r| ,Ii i i {rr,, pr r , lc s t r ' lc sc ro i o g i c (' , l x ) ri ro (l i l i c i i .t' i . l () r:l i rr 1r" (l .l L. (crr pkrr ( rl! r zi r I|| 1(I( ) r ||iI r I r r r ilir r r l i x ri l rr| i i ,,c tr p o z i i .i v i i l rl o i i rtl r(j i i i l or l l i .ri ,r' rr l i l | s), (,IIrrri | rri i rrrstrr0l rti rr 1 rr . r rrrrrIi l i (, ir liI r r lr r t pilt r r r , 1 i 1 x . rro rrl i ' c l l tl rl t,.trr,r' r' i IrIt r r :rlr ; i ) l l o rrr lll r r I iI iI ill rrIr.| | 1r' \rIIIri rrl rl i { j s i rrl l i rrrrl r, rrrri ., l or,:rl i zi trrl rr srr
' 't !

( |\( r '||['l ItI|1 l I r r r I r '. r ,rI t t Ir I t r, t t I : r I I i l t i t t I t'I t'rr t I t i I I t' I t l l l r ' tl r 'l !l l l l l l ' j ) r \l l o l r r r .l r l i r r :r ' o tr ttl r ttr t tl tl 'tr t l tttr to tl i ' rr I r , r r r r t r r l 'r 't l l i ' i ,r 'r l l i tt,r r .l I r i I : t I r' r': r I I r ' tr 'r tl t l :r 'l r cs, i tt '. r l tl l l l l l t( 'i 1 l r r ' , r . . , r . r r . 1 ,,|||II||IIIII l. l1)i l)' ,, 11 . r r l ( r ! l l : l t l rl l r l i l r' l r l r t' i tti tttr r r t i tr ( |) r r l i t' Ir ) Ir Ir 'r 'i "i fi r r .l 'l ' . r , , I ', | , l ( fl l t) l r l l l l l l i l ' tx) l l ( 1 1 \l l l l i r fl i l l tr ) * tl r fl i \''i , , , r 1 't r ', 1 'r i ' ; , t r t t l ll i tttl ,,t;tr '( r l l ' *1 . r . . , ! r t r , , . l l l l rl r' l ){f l l l t rl r o ;l t) , tttso l ,'i l 'l i r l l r r r p l r 'r 'i ( 'i l r 't.tl to l " l o l o l tsi i " l =r . l ' ' l l ) 0 j t' s:r l l r l q i r r l i .tr ( l l l r l 'l r o fi ' 1 1 ) r i l l ' \'; 1 1 l {':l l l ti l l l . r r r r ', , , , . . , 'l , r r r r l r 'r t l o r l l lrllrl ( r r 1 1 'r i l l r sl :tl r l i r l ( tl l l l 'r l l ' l !l r |f r r , r , 1 , l r , r l . , l ) l r l r r | r i i l r r o l ,l , I i l :r l l i l l l l \ l :l t l r ' l r tr r t r r . , :l l l l l r { , l r l l l :l ' "l ' l 'l 'i ," t r "r l l l i l i Itt'tr vr fl l l :r ' l l l 1 . , t t t t ,t t t u l t t r r r r ttL t r r ) S1 :l ( 1 1 'zr r r tr ttl l i l |l 't I l l r r r r l l .r 'v,r 'i , r r , 1 , r r r l r r r r r r l r r r r r t i ( 't'r r r r l i ;i l i r r r l 't r ', l l fi ;t'r r l l i s,.l l l {i l i l tl l r l ct fi St'ttl t'' l ) r l l i t l l r s( ) ; l ':r s''tt, i r t si , r l : r l t r l . I'r r '.r i ' l,r' lll,ir r ') N ,r 'ttt'r ttti r 'l i l ';t' r r l r l l tl t :l ( l tl i r l "i ttr tl :r r l r ;, I , r r r r i r r l i l l r ' ; l l r r '' l : Ir l,t,lr tIr 'Ir tt|' p t tttr xl ttl IIttti ItItII i tt 1 , ' l r , r r i 't . r 'r r l i l l r l c I l tl r '' r l I ttr tl l l 'r ' r tti , r l , , ', 1 I I I I I I I I I' { I I i i I l r 'r 'l tt( .i r r ',sr l p l i r .r r .r r ' | Ir i r Ii I ''i , , , , , , , ', , , , , , , , r r l , l , l r r r 'r r I i Ii r IIi l i Ii ' ' ( 'l l r z:l l l l l l l ' sl fl r '|,ttl i l r zl t,.r ,l r l p i i r 'r ', l r 'r l r i ' tcztttr r i l o t , l : t , r L r Lr r r l . r l r I l l l ,., 1,r r' | ) | I Ii (' - .I 'l I ( ' '. Il l l i l ; r . o l r r l r . , l !) ? i l ; l ) r "i u r r r r l sl r l si .."'l r r l ', .I . ,,fi, 't , ' l l l 'r l ( l 1 l i ( i ) r \p |i l Vl l l l so l L l l ( r l r l ) ( r tg l r r i , ( ,,]i , \i ,,, ,' tr;, lr r . r ! x 'l i r | i ,,,,,i 'r ,,i i r r i 'r 'tl r r l i p i ) tr vi l r l ) r '( r zi l r l r r ' , , , . , ', , , , , , , , , , f i , , , , , r t,ti tl l r I t t I t t I I rt t t i t ' I i 1If i r 1 r 1 l l ( r ( 'f'1 'o l ( l l l zl l l l r r r r ' , r ' l , l r r , r r l r o l r l r r tl cttti tr l i tti zl ttl l r r q i ti i ' r r r l r '.i o ti l l l i t'i l ' o l l ti o i l ( '1 ) t( l zl l tl i l ' tl t'tvi l ttt i l l l l i i si \'l i ', r , , r . l " t ', 1 r , l r , 1 l 1 r l i ( i l Ii o l l l ( 'zi l l l fl l ' ', 1 , , t 'L r t r r r l l t r r i r l l i tl i zi l ,l l l {r 1I I i I I I I t I I (| ; r l ) .l r ) tr cr ' I I r l tr l i I l r t( ( 'i tl r i , t r '; t l)lilr. , l cl l l tt r ') l r i v{ r i i ' l ' l i l tttti tl t r l r l r r z r i (l r o r l l l tti Sr l r r l 'l l r l ; t . l r r , i , , , ', ', 1 . r , . 1 , 1 ', l r l r i ' l r r ttr r o r l i s tt l l 'l t t t t t t t t t t ) | |||It |t||tt!Ii 1 "t: ttt r l r :l r tttt'i u i sttt tl tt.tttL i t: l t) g r l r tg l i o zi r l r r zr ') ; l r l t'r l 'l 'r tt' Sr tl r l t'l l i i ( l tr tl tl r t ,' lr, r 'r , , l , , , l r r l , , r r r r r ;r ttl o I'i tItI l r r tl i ttcttttt , I l ' , , 1 , | , , | , l , r 'r ( : r l t o l t rt o p t'i r r i i ' r r r r 'r l i l r r 'tl i l l l l l i Ir ( l l ) ( !t) 1 i l tl l i r l !) 'i 'r ') r r l | , 1 , '1 , , , r , l , l r 'r r r r l l l r , l ltl l {r 'tttl l i tr ( ( l t:o ttr ti 'tto t'l r tt,l l ) 7 fi 1 l 'l l r l tl l i g l i o r r t" ( l tr l l tl l t l ttt ( j ( l l l l i ( l ( ||l . ' Ei g i t,Itt,r l l r t t t 1rl l t i I I l i | | | 1 ', 1 | | , | '| . 1 | I l | | 1 : ' |\| i tt i r 't'i l :t i {) l ) i L l ( l g tr l l l ( f lll(1rl r r r i , r , r l r 'l r r 1 r l , r r r r l l r 'r 'i "l 'l l l ( '.'i i i i 'r 'l r l i r 'l l ,'l r '.r '1 l l ', r , r r ', l | , ' i l 1 ( i ( ) |1 t | : I I ( | I t ' i ' 1 l i t l t l t t l r r 'i l l r l i r l cl r ', , i t',tl r r , ri ,. , , , , , 't , 'r '', ,.r u .l i rl 1 ,,., "ttl tt '.' . ' ( l l J7 l ) r !r t l ) l ( ..!zi r l ' r , , , , , , 1 " " . , 1 , . , , : r ll ( . r '1 .r 1 ,. Ir r r l i r , l r l 1 l .r . si i - r ( ..i | ,,i., i r {) t]{r tl i tt l r l tzttt'i ' r l | r 'l r r r r r { :r ;r :r r l ttl l r r tti i t'i o r i l i l i l l ( f i l l l 0 , L , ', ' , l ' I l | . . 1 | . . | . l r . . t t , r r r l ; r I l 't '; r I r ', r ll 'r ttttl l l '( ) l 'i ( :||l Il l l tIl i l l i ( j l l l l IIl i |,1 |t.{) z( 1 ,|) t'l Il ( x'tl tl i l l 'i l l tl tt- str str tttttr r tl c r , '1 r l r r '. r r r , l r ,'tr r i ci i , Il t r ttttsl 't' ( l l l ztl Ii u , t , , 't , , 1 l t Il i l i tl ( r i ( l l l l l i l l Jl ' tl l r ttl tl l kr i ttl ''tt'i ( ,l 1 l l j i l ; d l , l ! ', 't.,r,l ' r r ': r r r r t o r : li l ztr ') ',t r l r r I) ttl i r r ci l r ( i l l r l ;:l .''r l :r .l r ', i ;r . \\l r r l l i r l r l l 1 ) l t{i r r r r l , rrf,, ; i,., r r l i r t h i l ttt l r 't t l , , 'l l , l l r i l ) ; lr ) i i 'r r l i r r' ' 1r: r I i i I r' r I i t r :r l t'r 'o sl l r .r 'r 'zi 1 i i r t , l ', ' r I I I'r sttr l l t'l t' r I I I t t t i t t I I t I) i l 'l ) i l i i r i ! l i l xr l i p i l ' , t , 'r , 1 . , 1 , , , 1 i r r r p r ','zi l tl r t 1 - , , , , , ', ( r l 1 :r l l l r l l l i i l zr . {r 'i r l ( r i l tl :l r i l ( ' l r cr r r "r "r g i i r 'r l l r l | | t , , , llt.. .r ''1 . '1 , , l .l :r l r ', f , ,,. t , i ', . f l , f , . ,tu f,,,i r '.r .r 'ttl .r r :i r r l ,r :l r l r ''r 'ti l ttl t'l "r ':r tl ( i 'r i - "{si i l l l 'r r ' i l l ( l i vi zi ' Al l r r tr r .l :r l 1 ) '/l ) S( r o l l , Il l l r l ( r r i r i l 't r . ', r r l i l r r l r t ll l l l ( ( ' r ',l , r r ' l l l tl l tttr l tt i tt i ( ) s( i l {) t( tl i tl i , , i l ,r l t't i r l l 'l l ( ( :r l r l t,t i 1 1 i | I I I t i I | | | r r , | ,,,,1, | I Ir l l ItItIto i r Ir I r r l , r r 'r r 'r r t r l ti l l r ' l r r i 't i tr cr sr ' p o l ' r l t'zvo l l l u l tsl i r r r r l 'r ' rl,, rl ,l I'|| |tItII|| I,'II) i II!I1 . r i i III'|||( | I I | '| | | . | | I i | | | I I r r/, r 'r r r .r .Ir .r Ii r r 1 'r r 1 r r Ir I, IIL I,|,I|, ' r '{i r r tr i 6 i r r i ' r r r r r 'o l r i ', r r l i l r t :r l l l l i i r Ir tr , , , , , , '\r '" . , , , , , ; , , t , il,,., , ' "p l i '' ' , r r l "l i 'r 'l r ' : r I I i i t t r I i t t I t I r' l t l r ' r r r I t ', '1 , , r r r l r 'l r ', '1 . tl zr tl tl ,: t,,, tIi tt''|'t|'' l " """' r i til i i cl r z rt l i ( r l l r l l l r 'r ' r l l r l ) l r j , r , , 1 . , 'l . r r I r r . r l l ) r l l l r l r r l ttr tl ttl tt'zi i '<'"tl r ;r l r 'l i r ; . \i l r l ( '( 'l l tt' l t'l l l l l ' l l t'r \l l l U l ) l l ( 1 r IIIIi i 'r 'ti r tt:IIi 'IIl i i fi l l r r , , 1 , , , i . 'l l , rlr I1;(,Ilill (r rr t r rr' 1' I , , , ', , t , 1 ', r , , , , , i , , ,Ir cIi r r i Ir r '' '\r 't'tr l i ^ tIcIIcttI'ti |II'r 'IIIi I i i l l rr "l 'r l l ', , , , , ttt i tt'tr r l r '[r 'r r l c l r tl r l r vt't;tr l r l r ' i l ti ttl r " l l r l l t r l l l l r ' r r ,tl t,ti r ir ,,,,tr,,,.,,' ( l l l o l l ( l r ' l r l l l l l l l l vr ' i .r I r r r I r r r l r 'r , l r t l l r o t l tttl l tl t ; r ') 'l 'r r 'tttl r o zr 'l r ' :l tl r 'l ( 'l 1. 1 , '1 1 ', 1 , '.t.I

rrl l | r' rl i ' ri l l l i o 0 -1 ri | l trri rl rr,l i r, l) . 1 r'r':rl i z ; rlr c t r r ilr L' gi; r, rl r.rrr,rrrL:r rl r, l l ,l rrl ,,vi r |lt i.L l rn {'rl (1 1) , 1I t )i, t ' r r l rr s | rrs O c i i tz i , d j } u n (1 , rl c r| rl r,r.r,r,l i rri < r, o hcrrr pllrirr rlrr I)Nr'1olol)lrsijriJi o rrmaurozi:i, prin atrol jri opiilr'i, rlr. :r<,r,r;a6i pltr'l rr r I r'ocrrsrr l istdrernir: (catc intcr.eseazii,artera ofi,lt,irrrici,).

ll\ Ilol.i. .sistem,ica : a) Diabel,ul lealizcazi, neulr li toaico-metabolice lrrl irr,rrlrl,ici, dirbctic5,,. relatatii, destul de frecvent in evolulia diabetuh rr.r,rrtrlir,hiirr., cu, se_ml al bolii (Skillern qi lackhar"t,' 19i9 ; Duk -inilial optic5, diabeticl (retrobulbarl, adeiea l,llrltr si Scott, 1971)-.Nevrita ci:rlii ,ri crr ,,pu,pitjti,',) nu este atit toxicii, ci mai alegrabe froclusi, rrrcclrrisnro vl,soulare. Apare in diabetul zaharat cri acid6zi,. anro-a .rrri.rrsiv lrl biirbali, este dc obicei bilateratd,, cu evolu{ie cronic6; re;lizil re:'irlcrtir vr:derii (cu scotom central, inilial pentru culori, in Bpecial rrllr:rsllrr, ultorior gi pentm alb-negm). ModiJicirile 'papilare ( rrl,r' o rlccololare cu predominanll temporald,, la ilebut iuilnalu-se in '.r l, n{)monr, ('rlomatoas{'i b) AnenriiJe, in lpecial a.ne-miapernisir ;rlrxirro ndeseu novrite- (neuropatii, n.n.) retrobulbare (Oliva;ius, 1961 .ltrru'n, 11,6I .r(,lH('lr, pofineur'onatiil 11)61 - citati de Duke-Elder $i 19?1); c) cj pol Si Scott, 1971); rrrrLlil,iorlrle, oarenlrare-, rur,r'rl,ronllro, oarentriale-, diqmetabolice pot atecta o'rsmetabolrce qi' nervii afecta qi nerwii optici (: o (lin pclagr5,, din beri-beri, din deficientele tle vita,rnini, B,; rrrirrozrrlo lilro|Irlvinls din su-ferinlele rligestive cu fenomen ile malabsorbliil rrlrrrr4rr,l,iile la etilici). lt) Sutcri.nlele endocrine (tireotocicoza ), l;)_ l,olin.euro?aliile paraneoplaaire pot implica qi neuropa,tii r-rrlrtrr)rli opii. lI) ln trlt,imii ani se relateazi, aparilia de tabloud clinice de p:rlii (irrclusiv.l,ablorui de ,,neulomielitd, optici,r' asem5nltoa.r,e cu s rrrr.lrrf )r'r'io) itr b<tl.ilc de colagen,cc, dc ef emplu in lupusul eritema (A.l)ril $. Vl ils(ltnenbcrg, qi co1eb., l9?2; Shephcril -19?6;-Fulford cirl:rlr..llrTl ; \-ii:t|. ;i r'ulrb., lg73). ll 'ltor:itt u:oqene fi.end,o.gene(ambliapii gi &md,uroBe to(xice . ). S_al rl.r.r'iri rr.lrrrr.rrrfi Iarl,oli toxici, care pot, sii prorluci, nevrite (nouiopatii) l.rrricr., rljrr ,clro lt)(fnliorilm pe^coi mai importanli (clupi ,\hnoGscui l{rIri 11iI)rrlc l,)klt'r qi Scott, 1971): r) N icol.irtu, delorrninii, cele mai frecvcnte amblioDii toxicc. rrrrrl rl rrnrxriirzi'r cu intoxiclli etilici. Arnbliopja tnbagicii este'b lrr r{'oiorrr r'rr rl'oiorrr rurnhal rurnlral (inilial pontru pontTu rosu r'o$uqi r.erdc) caxe verdc) cale u-iterior se poat I ox -tmporale Irrrrlr spro zonrlo_ peliferice, indoosabi superioare. Uieoli rii, rrpalri palri rnili rrii, rnili multo mullio Bcotoame Bcotoame centr.alo centrftle cu rtrargili mareini difuze difuze (Duke_Elriei {Dr:ke-Etd
lirrr rl,l, Mi l ) .

llr t t t r ii t t t t t t t t 'iI I r I i ' llt ( 1. , I N t' tttnl ,ql i l ' !,pl i tt ii lt r it t t t t l. lr t t 'iir lr t cr lf lr ( 'r rll'l) ( , ll l l ,l l ,trtrr' l t 1rl ,i r rrrrl rl i l ti tr r ic r r r : 'llt r sr ,r,lr r cir , t lr it lc r 'l, r r . ) 1i sr r llll\ ll, lllil'lljl, I |clll ill' I t lll r , t t 'll s( 't ) l r i ,,1,,' ,' l ' rl ttl r:rgi crt: : r. t t rI I I i I ' r,r ( r slo ( lo ol) i( xr i r lo lip t clr olt t t llr lt r ( r r t r tt t\tutol )ttl i a opl .i , r 'iit t r t t t ': . r t inii '. 1i.it 'slxNll'rttlt r plr lr ilil'li'' (r r t lt r r [ l) ' pol[ 1, ( rI 't r t llizlr t {llll tIrl ,l t,,1,rr ,' ,r' ,r," ,1,,,r,' r rl . Itttrl l o.r'i r r r r iir l'r r Jizii ( xlt l[ ( t I x) l'{) r ii qi t lt r I t t l, t r t lxllt {'ir " llr r t i i ,,' ,,,,' ,,,r,i I t ivr r lt t l rl rr rr r' r rrl l c ttl t,tti frr sll-it l liilt r , t lt t t t t lsllr t l'o: r 't llill( ir $lt t t gt t it t o, llt ' ( pr llit r t : t t r r t palii) ' p( f I 'it or it r i I l( ) r 'vilot ' Ior' 1i l l r Iri vol tt l IrIl .rr' r.r, llr' t t ivr 'lt t l lt ( r lvllllli olt t it l sint '. r ilt r ', lr t t lit r r lt t s" l l l ttl r:rl r,l i i l rtr.rrfu - i. lr t : "'t t t t r opllt slt t ozit , ( Zilnt noit r r llt l, 1{) li{i; I r llt r lir 'l r yi ir r ,,, ol rl ' i ctr i ri l ri It,ti ' | l ,,, ,,,,t,,, l l tl ,u r:i l rr{,irlt I ) tI Ii I ri I')I rI trI r ii Sco1, [ ,1{) ?1) , ct r t r it r sii' I t r llizt 'r t zr t ' Ir ,,1t, rr.nrro rt,.ttrri Lt git t o( lo $llf of it lliii, ct r lilt l l'. u'tt ttlol1irn, cu'. srttt ,lrird rrkrlil lr) ,\r'r,rrtr,/rroltlitrt tit'r ir:a ;ilsatt i trt sii' r r pr r t r iI I it 'vr lilc olt i'icr o. t nult o 1xr 1' I "or liiir ,u ,' t,' ,,' ,, tntdt.i pl i i l ,!. , 'lI ') . ( l( 'H sit ll I X) slill[ ( f ( i( ilr ll${i ,rt l rr ,,,trl ,' rl ttl i tl ,,,ti ,t t t ct ^lir lt t lt t it lilt it r lt 'cl'iolr sr r lr llllllr l lllr r r ( r llllt li r l ( ) iu ir r t 'ir zilr lii o t lollt pliclt lit r , l tr 1,.rr.rrrrl | (1{ i ors|) 1r, ; b) ( Wllslr 1i r lt r l'ult t : lgt t r sit t t r r r t i , , , , , t , t i , , t , t , l i , , rl t" ,' i 1,,:i t t '1, . u", , *, , ', ( 1ol1r l'''I 1l?l'; ' ,,,1, i t,,,,, rl u;r' ; trri hi r-tl l lir r lsi li( lir t t ' 1l) it 1'Nilioskr 'lr r ilr oll iii clr 'r r ls'r t 't tlr t r r cizr t 'l l! ) ?l) , t r : , r lt cllol, tt i ,,,,,,ri ,,,,11 . 1{t ?d; 1l'o ri l ,Lttri i i rrrl i ( l( r "d', , i. , ( lblt r r vicir r $i l't ls( ir l' r t lr i N, lI t ( nior ,, sit r l; t *izlil, ll rrrt,, r,l ,,l rrti i urrttrol i rgico, lit t , , ( , \ r . il, 1r , l, t i, . ( , ( r r . i r r ull. l. . r lr . . jr r r r r r r l: rrl, f;,..,,,, ..1 t,, .,,.1ri r' t,,,1 s, . r 'i, . , 1, . izo t l) ir 'r 'olr l' r r pf icl ir t ililr lo t r li'r 'ilr r ,,,,,,,,i ,l r,,l rrr' ' rzrii,tr' cllt h'ul ll. I l', s: r t t llll'( r lit ) l t lt ' sll' s( ' illiJr '1'( iit s{il'i' ri' l it , r ntonosir npf , t t r ir 1,,t, rrr,l , 11, , 1 ', t t colr r 'lr ', (M c Alf ir r qi g, , lr r t , . , llt ?: t ; Nilt r . 'sl<r 'lr t ilt t rqi rrrrtr. u,,| ' ,,, ,.1,,' $.,1' r' ttrl .trl tl ,

, ; Sclr r r f cli \ j , r i coJ. r r lr .l1l?'l ' t l rrr' 1,r., l i )7i t, t9?l ' ,; t r lr , t on'e llllli) ( 'r olr st t r t lr iI r ' r 'pl'icc llll l{! lt lllr ) H( 1 tOi 4 ) ; t l) 1lr iLr , 1i, l rr, ,,,, i 1i r' ,,l l r' 1r., i{' l\'l'' ,r,, l, , r rrir*'rtttistticttr,ioilitogrlrii",r',ir, S.ll. li lrici-lllr .vrllrt(lN'zi' spnr ([(1.,t'tulzii Itrrpttrtrizrtlri ,p'ice :titt ttearttr:Le l,rr,lriotofico rri,rrIilirriililr of rfr1t

11)'il-i S.rr,l'5o.g-\\7,Llh.itn, I Srrr.llx't' r',i,i , rli;l'; i,,'tri,i-;i'tt1a5.,'J9?+; O liilr r r r r r tlll{il};

rlo iilt,'irt il'i',t," ,i i t"1., .*u,strtatc iir clr'zurilcbillo tlolittil'tr ,,,,'1",i ,"i Li,', (rB1'{r ('llro ill i.tt cvolttlir'r, rlcci, o otnritili,t inrlelungatd, nil' ;t,, i,,,1,,,tt,t, (lJrr'llrlS'M' rii opticri rLt'vlitlr' ilitrh6 i:t'lrr,(ii ovllnl,ua,lelt, ni ni'rru"izirzt, 111it,r1r.i ll r1, ry llirrkrr, lll?it) . o sclio (lo lno(llllil'i'l'ido trll'o ii.il,i!. Morlitirtfirilotinlpului vizrtll oforrii,
lor, rr rrru.ll,rrur,.(]i!I.(l nO p0t fUrniZA, Ctll rUli

i ii Jattt'or cll'-osiovont'ru tenionattt, i',,-t.' *iii- t,iietetia i'; ,'1, ',;;;';':;;;d,,'ilii l l l cl l tn l n a . c l r r c .i t l t " r " r l 'u n n i a i t)(. D l l fe r n -" a otnptt.tu i.c alterdre 'i.,,:i:,:;;i'i,,i i srm,oloui prli,,ip,rit"tnodat ittil "nt'gttrt'lrzl
(tlu![ ]\ri$Ili,rJi p.t o,,'., lu t'l-rt,rlt!r Ttal'oktgiac ",,rrr1,r)ndonlela 'l{)??; 'It,isir, flriZ; 'etnrsiA, 19?0; t)rrke-liklor qi St:rtt'l r,,t,rlr,' lllli?, lIirr (lrH. l); tuhtll'driN ,r'I).ed(tca ''' r.t.l) orhi'r'tt , c:lro rctrliztltt'zi' ,rrtirrru'mJcranlitltii" ttrtrrr novt'it'r'l' lr) (prqrilitil); jL 1,11g,,t : r4 novi:itil,opfi,IL xtrr,birllrrr,r'il' r,ir,zi'1, 1q1. r ii l c) iHl'irrio, Ir llr,r
r. rr| | t

a'tl0SOA, l)I'l{)iSO OOR'SpOnlt(llt['{!

opi,iri), din intoxicalia tabagicd, cu ovolutie oonici, Rple al,rolie oDtic{, t) Al.utolul. metdlk prodrtce mai ales ,rnevlite" (neuropatii, n.t,) opl,irlr u,rruttr cu:lmbliopio soverl, lar care BoaBo{iuii I miihiazl, parezo $l; (,xtrinscci oculari (cu diplopie, divl'se strabisme qi rrrrrrrchilor' thztr pol. prrlrllli),) gi alltr l.ulburiri ncur.o-psihice. d) N uropalii opticl ?rin dioerce alt.e mecan.i:tnteloui<urmetabolkn tnllolJttttr l-rr,u mai dercris in: auJlrril$lutinnc, tlrnoli (nour.opa,l,ia r.4lt;io6 prlrunouphzitrrl),In trrtnrr, htmoragiilol mtsivo, lrr grtll,i(lil lt,l,rf, In ptrion. r|r,lo drr la,ut,tr,l,irr olrr,
'.1.4

b) Al<nolul ?rilic produce ,,amblyopi& potal,orum;', probabit pdn I ilxrvil rrntinozil, IJ, cu tablou clinico-oftalmoltgic a.semlnd,1.or eu nevrito

tlltoi lt'zitttti tIottI1tIt'I tntilttu.tld, l0 tllt.l,oltr6to ' :1.:1.!. o orhirc lal,/jld (


tl rrrv ol rl i tr (t llr lt lxolr i lr ir 't t lt llt l'klil, l't t t t xt t 'lt lii gt t t t i t t I I I It rt tt 'rI I i r' ) '

t t r t t t ln t t nil. alt ul, it lt t lr o lt t lt 't lit t t t ot tt t lt vt t lt li ollir r ' :' .:.' ,:1, IIn ttrtol ,o'nt , | |' |, I t| r' | | \ ' , : l. t

clM P VTZUAL

'' :' :!-4. Iln tT)|,.r'ttt' |ll'rr t tlvtrllllr0t'ptrttl,ttt unl'rdl hrttttirttto,xiahrtlttt'ttrtirtt | | l ,' rl r| | (\ l oorr,l i zl rLi1xr r, 0hi rr st t llt olt , f it r i! - l) r r t nt t lllr r r t 'i, lt llil' lt t t t t r t t 'ilo t lt lt '1 (!illl l{! | ,rrt t rI rt rrrri i, 1lt,ti,ult, 1xrsloliorttil, a, cltitstntri, tlntlo trHl,ttlocttl tlo i I Icrtl (x)lllnll l l,t lt'l $t hctttirrtltt prodtlco ttlr $(ltlt,rtttt rl liltrr'lor trrttlttllltr, 1x11, Irlrrt rrrlr o lll,oll,r'u jroi'ltcrfcri u, vtrlolii (Il,cllv, t!)(i2 I Wilsotr li lr'rJ(x)ll(!l r'il,rr,[,i lllllr{ rlo I ) ttl<c'lt]ltkrt r,{i Scotir, l.(}71.)(r 1'(\vollll'ot lxrrl' ' :1.:1.lt. lln ;tu,l,onrc(lntTaLhernia'n.opsi,a hontonim oiJl l|tr r, lIziIr(, Irxra,liza,tir, 1xr zona postolitl:rrii il chiasrnci olllitrt', 1lo ltlt'tttlr' l . l r r,l rl i c:' i , ol i 1rr l xrl uI o ccipit al.

I 12

I \3

cAt ontcE

njj*iHiili ll l;':1 lt;i'i,''mliii,{i"',';;, fiiii,l

Fasciculd(' rol! :: nlzfllt Dl'rl(n,. lr ' r I r , r . , r lt r r t ( r 't , , r ,

'.:'.i!.1;. Il nnian opsiiLe hetaro'nimeb'item'poru,le se ittliltLcsc itt [r:irrttilr de ttl'tniii.<r:lttltr rllixt{,itttli; t,t, tlrtrttr rrlr t irr,sm.ei in special oytlice, t."alizttte l i r' { i rrtri if um oi'i schr e {in( lt r ) s( {ii hilr r r li. b) t sagi l ,l ,k, i l c c ir iasm ci; 'r ,i,|,'t rorr,rtiir, ttlcrtoca'lcinoame, clrcinoarntl mel :r,sl,tlt'i(Nl) I .tr) 'l'ttrtrrttl ,l rrtrr (tttotti rgi oame par asclf t le, t nm oli alc gllglionulr r i lt li ( lr t sir lr , 1r,rr ' (ru ' Irrrr| ' rr rrl rr osrrLui rfonoi d ( ost eoam e, ost cocondr olnm o' slu'( x) NlI l( f ) lllllr l rr, Lrr)rl l t(!, 0l t' toi noa,me, salcolm e r nct ast at ict ' li. a. ) \ si chist lll i : t lc t r t t 't t it t ,,, l,,r l,rrzr ti, lrrtrxxi (orllitale, :nazale sau nazofaringi{'tttr ct: ittvllllttr' rr l ,,r,, r ,' r' rrri rrl i ri ..si 'I t t io I r t t it l a, zoi i ci p am solar e) ; 11)it 'r ulor i supr '2r solir r '(olt t.r,,,,rr(, | l ror)i i l gi oamc S up r asellr '1, ,t ut t r or i [ i abcos, ol c lr lt t t lt li it 'r t t t llt l I,ttr,,rL rirt rre,trlrtiiuiirnoame qi nl1e trLmori nlo ventriouluhli lrl ilcilt'ir' ltitlrrr ,,,1 rl rr, l rntrrtl i opi tl cunoi do, cor doam e i c) Tu I O I 'i pt ost r llt lr ' ( lllll, i llll) ttt, trrtr.Ii ol l l tt(r l r,l ti i i anl uhLi olf act i\ '; f ) Ant vlisr nt l llt r ilt t clt i t r it lt t lit lt ' it t trrrr, ; g) Arul'r'isme ':r,1o?r,rtct'eic;municattllc ilttl;criollttr I lt) l)r'gottt'tlr ,i irl(fto. sl,u :rrtoliosclerotice, DIin sclelozti oblit,cm,ltt'ii it tltitrilttt vittt,' '|li ,r|, ilttttttirtittri ltolrlt'i;1 r'Irrrrritttrri rle arlcr':i corel)rrIli'1, opl,ice;' hcmi i) Anevrisrnui anopsio tl rrl rzl zrr rttttri ri o llit er npor all, sit not r icr ii ( FI illor r . . si llr r 11, l l rr;l ;)t ,i ) i J-i ru rol ata,t \,i cit cva caznlj. dc ancvlisr ll 'll l\ r lt r t 'r lr : r zr lr r r r tt tt't , tl,rir iiirloliol prirl sp;tiul intcrpetiuncular, ott ctttnplitnlr t eit t rI t i It r't ,' l rl ri (1( Lr' r' ou d, i off , ci tat , de. Duk; - Elder $i Scot l, 1{) 71) ; , k) At 'r tht t oir lilr , ,'jrl,r,'liitsrnalice (poitmelingitice virotico' bactcl'ierrc, r'ickti,l'siozitro, Ittl ' ii ti ,r' , l trl xrt' t,ttl tti tsttitraunr alicc) ; t ) lf : r lr esr r l f n, ir t " 1( ': r ljzir I I( rI I I i II I I ()I )N l ,rl r" rrl )oti [l o, rcspti ci i v l l i tuzalt i, t lr r r t 1e cclt - nt lt i r t t t lllt ' r r r i it sit t t t r lt icr '. ; 1 ( x'it ( llr ( ^llilr , {( x'ri( n{ ( olr t 'plr t cocicr ', Jr r l( 'ulr t t x r, r' tIul :l l r: i t' 1) l l ttri ngi l .cl ' It'rt'lizlrtzi St'letrrzrt trrrrlliplii, rr) r'rir irl(,s); rr) lri t vrilelii r-rpio-c hia'smatir:r' I ,,rr,',rr i ltiritirinopsii bit'cmpnralc pl1n lcziul)c t,1i:tstnrr,lici'i(l:rt tittit' sittt;tlrtttl rrrr(i rrl ), i tr o116 sht neci) sar e ir r vcst igr lii l. t llt r u'lit t ir c ( ilr r lt 'ost 'bi t t t 't t t t r r liagnost lr . r llr r l r lc lt t t t t ot i lt i; xr I izr r r i r.' rIrr,l i ,ui cr' ) rIr rt:rl trt' i u clir nililii t l ,' , 1,n' fi l \i t' I.rr, l l l ?:,; l rt,bot : zky, . t C5; t j; p) 1lI t t t t t ot ik pt ir r t it ivc r t l'' t lr i: ', 1lo cltirtl rrr.i rilrlirxr (gliotrrrclo, ganglioneulorrrntlti)J r) '-llrrrn,rri*.1,11111111111 rrr,'i olllitxr (gliaa,mrr iau rirenirrgionmo do ncl'v opt,i(!' oll ittt'tttllt$lt' tLltitlx ri ). r rrr f{r'ryiitr <ri't, lozitrnikr rno(liiilo l1r rrivtrlul chitsrnt'i opl,i('(" (1ill'o il[(('l'(rrr7 lrlrr'('l(' llttzlr'lt\ (caro so i nct'uciryoazir,), . tr)ro{luc tillitlc rltlilllr ll(rltliil'Itol)$i(r lrilcrtr';xrrillo. lia,r' brobuitr ticoirlat,ii riurrrr iltctr{ it . ttt rot' irslorrt'o it'li1litn, lt t r r r , t i h ipr t f iz'r lt r '1 ,r' l r' r' :i ,l o tl tr ttttol * ,rocoso f i) r I [ [ r t t 'r 'iir . t 1'j's ( r lr r r l ir r r . v vizu cir r t p ,,,[.rr;trl 1,ptrxl rrr:rri i ri {,i rr,l dt tl t r lixr t r l 'i1lii, lt 'ir t r lt , lr .Ht t llt t liot t t (rl v(' l l l ,l l u,l I(,I| | | | ol .i l | (i i ttl ,t' " t t t tnit r gr t I r 'ir r r p vizt t t r l) , t lt t lt i' ot t t t l t lt t r r lt ' lt 0nt lt t l' ,,rrtrrl rrtor.l i trl o tl o tl t,ttstt;lt 'itp, , r i, pr , , r lr r i, ' it r i[ ir t l r lr , lr r r l vizt lt r lt r t lot t t ' it t ( l( ' l\ r l) llll ( ! lI ' l) r ( xx'$( 'h l l ;l tl nrttl l ' l o i ttl i rti ol l t' t,.l l i rollr r i't r 'i t t t : t i ( , it r lt t t $( 'r ll) l: r lt r r ) l) l, ilxtll( ll' ; t t r lr lt t t r t r i <llt it llr t t oi l rI| l l | | [[1i (!(t, vu,gtrttl i t,to n0 i, r ) r l lt lr t i l ll'l{r t Ii pl | r,i c | l i ,,nrftttl rrl t, t ili, , t r it t t lt vlzt llll l\ lr r i lt t lt ll, lll] r '! 'li! lll0l( r l r,kr rl rr| r r t r Lr t I t r

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I' t,' l l rrl rni n. 11,p1r 'zit t lil, o ( l. olr llt vir l'r glt ) l) t llt li r ) ct llit l' ilt r r lir t r t r t t lr ilt 'i' l frf,ff, l l rl rl l l r.rrr.l i i rrr t t lr illr ir , r r r ll iii lr or r lr rt 'r , r t liz: tlt ci . 'lt 'r lll( ': : t ) l\ t lt t t . it t t t lolul) lr ) r , t t t . llulut ir t nt r t lt t r r li: t '\ t nt t hilit t r nul. l frrfrrrl rrrrrr,rtl rrt' (r,rol ir r lt t t io f.i l .l . ,l pfr,r.i oInr r linir il $r , lr r r , r , lt t t ': t |ot '1, r , t t I ozi( ir r r {r t lt i'( 'i lir t : i r lt ' (' i rrr, r11r.11111' t r' ol r r r r ll t lr r : r t |'r r t lr t llr f lr lr t l|r 'lt oit si. . '\ lr t |r 'i|'t I lt I ot 'r 'r 'lit , l l l rtrr
Iti

in

.,. f.,r.,. . , t i t t r(ilr,:r, lrr.rrr , i , tI I t t I II t , , tI t , I t .t | \ , t l r.| tl , l rl , r,r.r.l ,rrl tri l rri l l r / : rt l ,rtl. . tt(' fr :r1 ,. liitrrl tlr . l; , lt i t 1111, , , . , ,o Lollr . r r r t r r r l ( , t j l n n r ( l i l i , l , r I I r1 ' I lrt : I lll| r1.t.

l r r ! ! ', r , i

r r r l | r | r l c l r l r 'l r ' I '

1 r:tI'r Ir r ;'t'r ', t'r i sl |'ttl l t

tl c

r 'ttl l ttti

1 t|t|t'1 r ttI|'

tl r '

ii .or2r. out..r-era;"'ii 'llll:;: "A1#""riL 5iL,opoui,,r,r 1jo;r1. s..ii'tiiiil I lr N(,|liii;i,r | 1 ,5 0): (t


I t l.'.r,'Jlttl.ni.iproduse pri tt Iezi,r 11 i ay6I1o.o"u1o,,". ;, r |,(.ztutl1 itte lereti]or orbitari : osteoame, osteogarcoame, ma.lli ,,",,1,,,.t.i

;;'1 i11,"!"ii' ':":'#lilJi' Jiliill;: t,. i:l.iiiliil,fj'iiill$"}"f,-,ff ;"x]1, 1;; ,iir' , ot"*Jdd-o gi,r,oiiii'u.or"", r,,,,,*i,, :;l;l;l rr r,r.rrr, rr: i',,,lli;iill"i'j:.11r, ':]::il?ly.3. r,:r. ,,,.rvd onrii.. r;{;1.1:;g;if.b"*",i"iji'i#rrl,,,i}::;t,;i'l],li ',, ,rrf..r:.ttri.tiL (rr);; patri gttipe dp ero.ftatn;i,ri" ic sis[em:rt.jrl

l l ) - I( tl l l l i l r l l l ) i l l : 1 \ l tttl tr tl i tr ttl l l l r i l j i l 'l . r n t t t r t t t r l r r l ti l l l i l " l r ) .l l r zi {'i l r g l 0 l r l tl ttt i t'tl 'i l "tt'; r Y t 'l r ) 1 , " tl t l l .g tttttt ttl |l o t 1 "'i l ,r, r io lt "rr lrlllill s:r r r ttr t, i tr tr ttr 'i l ' l l r '. sttg tr l l l zl i sr 'r l i l tl 1 1r , l , , , , l l r l r r r r r ' ( l l l l ( r , l , r l l ,"tl l tr t'rt I 'r l , r r l l l r t r ( l l l i l l ,r,,1' l!l ,,,"l "i t'l i t' |r ) zl l r :l t'- r o l l r r l l tr i l 'i i tt Itttr r '{i r '( l t' I r r , r , , , , . . | \ | | | ( |: I i ( I ; I I I rr r l r i i l ti l i l l l l ( 'l r l t <'t ] t'l l ' ( l ( ' (x rl l l l )l t r l r ' i l r l l t t i tr l r i tl l e ) l l r l r ttl tti : r [ l l r l t t t l t r 'i r r l l .l l t 'i l l |r i r r r r i .l }l 'o \'o {'1 1 1 1 '\ t u 1 ', t , ' , ' 1 r , |i l r r ( i r r i l i t ' t t t t l ""t' si i l i t l r r; r l r{' \Il r '' ,l,, t|"rrlrrt l r t|ttl :tt'' r l r ' II|:IIIi l i r i ttt II( xl i ( r l l r r r l i l r l l l r l t tr ] l , , r t , , l l , { i t t r 1Ir rt I I t t I t 1 " i,,,,, - | | | I I: I I I i II I I I I | ' ' ' l t 'r . r l r , l r l l l l l r 'r r "l r ' t'II'tttt'ttIt : l tsttl l tl l ttl r tl i r l o l l ttl o : tte .i ttl tl tl ttl 'i tzi i t ', 1 1 , , , , i , , t t i t l i t u l i r l l l l ) l 'l l l ( l ( 'l ( 'r l I) ,) t'- r r l l 'l l i l r tti t'i ; s : r r r ttt'r r ttl l i l l i l i l l l l tl l rrrl,,, rlrrlrlll(:r lt i r r ''l r ) l ) l l l l l i tl t'.1 t'l tsi ttttc t') , r l rr LJr ' 1, t , , , , , t i r , , , , ,,,ti '"'i 1 i i t""'t ''l r tl tl t lttrr, o r r ttl i tt' g l ttl ttr l tti :t i l i i tL tl tr tl sr tl sr r tt ,l) l:rlrr l r r r l r 'r r l i lr i ; ; r ', . , ' |t'tttti l r o tl ti l r r tr i ;i 1 tIti ttr b i l u t :i tl tl tu 'r tsl i ti , | , t t t l , t t t r t r l i r r ', t ( ''l l ( r l i ( l ( ) ( 1 i l \'( 'l l i si tr l i sl tl l ( l tttt'l l 'i stl t sttl l tt t t rr 1, , , , , , , , , r, t t t t t r i , , t , , , 1 t , ,,1 llt r,| , Ii t' tt l tl ttt'zr 'i l l tl t r ',t,t,t,t l t t t r t t i ! i I i i !i t u l u l tttl tti tn 'ttl ttl r l r '' r l |r tzi l t I t t t t"t', i l r l 'tr " r '' {'r 'r l l i r l r l .. tr r U l r 'l r tr r l ' ,f, , i ', - t ', , . l i i ' r ttr l l ' t' r 't ' l)l f "' ;ttr, llilr , il' l rl ( tl i tti tt sl Ir r ) l r l c txl r l l 'l i 4 tl r tt:,- l ) 1i ' I I l ': t t u t l t 't t 't r I r' l l rt I t t t ' ' I t t1 'l l ctl tl i i i i ' ttct tttzl l r r 'l i 'tti ttl r l :r l t l 1 r I I ' r r :i ;r l l r r t, .1,, t' rttt lrlltlt 'l l ttr l tt'* i s, i tl r 'tr r r 'l r ti :r i - l 'r l tttl ttt I |: I I I ' ' l l : I I I I I . t, rr.,,, I II , | | I . I : I | | .: | : l r 'r r l l l l r 0 r 'l l l l tl . t":i t'r ti ' ( l i i r sr '|r ''r tr '"tt I't'r tt"tttt ' t"r t'' ' , '; i , '; ; , i 't , 'r r rtr r ; ;;];' rrrlt lr' 'i i i r l t l tl o tcscl t'( 1 r r 1 1 r r t l . 'l\r r t u l u i ri trtl;i ''l h i l ttt'r .i za ttzi i ' ( 'r '( 'r r l r l r tl r l tl ) i s , '', ', , ,r, ,r r l , , 1 r 1 i r ', l r r r p i i : r , ,l ti l r 'i "" ;i l i 'r 'r i r i r l ,i r r r r i l .'.r ;r i r r i '' ;;,. Il ( ' r r sl l tzi i l r l l l t) l l l l i r l i |'r r tr r 'r l r . r t r l t , r t r r l i 'l c t ir,,.' '" r r l cr xr r r t i tt:ti n r l t'tttn u l ' l : I l . l 'l l a t t t i t t i i t i l r'l tr r ttr d i tr i t:r tttl i l e si 'l b so l tr l ( 1 117?): r r o l l r l r ' 1 t t r , , l t t t t , r r r I o s l i c t : t l 'l i izr i l c tl l Ar sl tti 1 i i i l l l l 'tl o r ' l t , , l t t t l t t t o t t t d ) 'i r t , : t l i xl ' :r ttti tl l i ( i I l r r l tr! t )I I t I | | I t t t I t 't | | r 'r l r t otr ':tzi i vl r l i l r ( i i l r ' 1 r l 'r 'si tttti i.i tr I't'Ito IIti L Ittr '' L t ' r l i t] l l l l ( \ p t'r 'tl ti l i tr tl c i i : r l t t t ,r l l , C r L , t , l r l ) r l r 1 : r l ( . I t r r ', rIr r ,.Ii b i Ii IIr 1 r ''Ir I t ' o

r'xo|IItItIti. ; "1 Vrrliabilillir'",1{t:ltl'11111..:.1.t' , ,,,, rrlrrillrrl'()l(){ir') ( i tr r l to tl l tr r l i tr ,r l i l r g tr l r sl i r r r r l Ii sl l tl t'i

l rr.z iur r i iDt r J or bita re : ale nerYului optic (glioame, lnot ,ii,r .:r(,rnr(,. r,r,..,.r,rt.r.lio,,,o", {,'it?,ir.ti^.,,-^ p""li.iioi.-;:'fi.ffi;;il:rl"r1*lTi",xt";lli, -^-,.^,,1:30ri ili,;.,lj;l:11,'.'"i,lll..,ill::1,""^lll{,i l,.l;r.rrr;111., fr""';;;;" "pri.1_"in,ii,i"""oiiioiuo.,I",,r

'r,,, ,,;,,1|:tzi,r,1 n::Lmdui sa,u a unuiadin p;";r.ttl;;;;ati (fonr i,li ,,,,, r, , r,,l r,'ri,,"r,"'"'"",";;il"l,,Y"1'i"'H,fliliiil :1:."1X,'.i:"li:i;; l r)

p"oces" io"ito'iitorii [cet,,ti i,;li']l)ii,]lll;'i'.i,*j,iJffi:"?Hff;jiilr"groa'n"'


ale ochillui : d.iversc tumori, facomatoze, glaucom, ,,,,,1i*1,,1,,1'ri,,r,i

i;;g,"'ii,i."if1i,r'ilt'Hii#j'rJi;ll rrrr){ r',,i,-i:r'r(.ti.'staze), lli l:ourn,"vi n. 1;urotiL,rofiri";;l;1 ;;; ihtfingh,,,,,

.rurr. l r,onl o-orbitare, mctistize,sarcoame. etc.) ; ny li"ffii""i.#irql, trrrr:,)r'r(r(dr.rlo(xic 'i"til,m"i"G lrouto-orbitare ; c) I,eziuni paraorhi ,1 ( . I r . , I I I | .I i t .| . . o.t

jilirtr,iy?:1g!f-t$d*e{;"#^{#:#y:!;:*{i ::ttr#"i:i,l ;,l,lii


' ' ' r.ii r,. I lrc es o) .

.tist"iui" a"i"lllixT#Il"i"rrit"i i',r.,,l*,, ti),rurrrori intro""n"i"nl, i ::.',:.il,l:ll::l , t,,,, t,rrrrr.r,i tlc ariri, clesfenoial,
iIlrJ||r:t1,,sr r.rl ntduralt.

factori a1 -pt.otluse' :,l,r. rnl rof le bitc ate-sin u,s\rlui ]'; liOit", '"iloii;;;r;;fi;;S.,'""Yi;,filli :]:,',, : : l l : i.i] rrrrli.r'; lr) tioti \.itsc.l'ro , """""oor,-r"r1fr

II,l t);ntl.trntii ...,., .,

prin,

cranio-e.mefalici:

tumori-_;il;fTril;i"ii;i;;ilii 'r,.,..'tir*., grionme,siil".,i,tsi;";;;"."-kiJiit. ro""ri,n,,i ::l',;11:l;1.,1:,1:!:1,:,'1.:1l_qit,i: r'1 \r rlr,,r'rrr:rlii ,.r..r'ioce'cbrale: iii'sto"gu_w"r Ir.:rt: trrr ti,',,titirt.Lirusen: ir Trr"il"i;;i;;;;;^i;Jrl urnaiis'nr,.-.,;l,i;;;"#"'lo, hcm:rl.,l

],,':ll:1j1.]: , r L'r|,r11rirrII{, y(,s.clall\-o r.egc[al,ivo sillrlalice sltn)a1ice


LL,I|'',.,',',I':'l: rIrri rt,i) .,i
I r | , ; rl ) \l )l lz ii

,1",';;i1,,,,,:l,l:: ,,1*tisrir;"r,f .u-.liiiii"iocrinr. i l,j,,ij;:i" ;:rt.riatr 1tril .) Iroli, s,r,.EJuine 1r.u".-iiit"rii#);'il';#;!ii"l;,.\l'l{ilil


; ) | )isyri,zia, Iiilu,ri',sii "noE"oit^l"'{oJfta,lmir, ,, lui riichte;;re;iitii^'f i.s,c"rri"ii cotat,.,r rrl x". c:to.f,luluzti : ful a) Co-nstitufionale b) Sindrorrr rrtrrr ; ,,,",,) 1..,,,,",i:.f:..:t

l\ t l ,).' , lt r r t t nii pt , r t 6 p D r,i tt J a rl o ri ,i s tc mi c i ;

r,1r'. r.rrrl.orrflrrrirrrri r, , i, .1 rlr.o|iuirr| or.liilrrljirl. r,r.rr 1,, 1 ;iit, ";,, ,, ., ; ,, , , 11 .,t lt,l,t,,t.irilr rtrt|,i,,|,,r1itr,. rk, lirlrlottlclirrir i,i oIlltlrtrrrlogir', irr Irrrrrr(ic 'l ttt
Ftr' iif t' t t : t t I t I t I ri I 1111 l r l r r r r t's p :r 1 o l 1 r g i r ' I I I r , , , l , r r z : r I t t r r r r r l l l 'i l r l o l r l r l r i l i l "l t' l !l "i i ) ' sr ' l ttr tt r r " r 'r r p , l I r I I i I i I l r 'l r ' .\r 'st'r r i 1 i l r r l r r l r ' ( tl l l i s r r ' l r 'r ''

a) A fecgi uni r:rrl ,

f) Boii conEenitale (e\oftdlmia, |r,rrl'r ; f)Bol) o,,ir

li,"r'rrir'rl It,r'rrrr'r,rr .rof1r:t'nio t".,r,i

llr , l) { , lr ) tj l o r o r.b i i ,i rri "*i-; .

"iliiJiiitli.,tin"

porr,r.u,,,,i

i.ll.il. I,irrrrrrclrrl conrplex al llnoi crioflalinii solicilir:


" .il. ii. l. l,l.rtt tn t tt rtI t,linh: ' : . , : i.,' i. 1./. .l nltttttr:tr n t int t liot r : t ii, t iolir r r lt r . s o . r r r or I I r I i I I r I i | r , r [ i . t||s I.i rl rl rl c l ro lrr{ir' (r ' , r rr 1i 1111 , q, I,r., r : t r r . . ir : i, i rr I r.r.rr r i I r, rrI I i ) . , i , , , ,i ,, , , , 1, . f, , , f , , ir(|( tltl|r 1 '| l "ll ;

r r l l r r ti l r i l o l , I i , t rI t rt r1t rt. l i i s i t t r l t l r' tl . o t l r i l r ', :r l t' l i tttl r 'l r r t i l r' l ' r i i r l rr l r' ;i :r l l n l tt Ii |''r ' I ' r , , , i l , r l l l r t t t r t l c . l )l r ( 'i Ij r ( l r r ;q ti r l i i :'l r ' 1 '' r '' rlr .r 't'Ir i IIL ti ' Il ,: ' l r 'l 'l r ' :|"tt 'l l , l ) : r : / , r , 'l : 'l l l . t ll r .:r l r ''l tl l 'l i l i l ''r |' |"r "'i "l l l '' | |||| "":|"i Ii IIIIi r tr " o tl r i l l r .l i i l o ttto tl t i tr l |i r Ir 'r r !r '' r li ttttr l r ' i t r , , , , 1 , , , , t r , r 'i r t r i r 'l l ( ! r r r l i ( ) q l i l l i i r tl t' ;;l i tttr i l {'t l I ' t | | I |{ )! I I | | ' fi r r l t : r r i i r ', 1,,,, 1 ' I t rI I t | ,tI t | | | i | ( t t \ttl t:;l ttttl tr r l r t'tttl tr ttl : ' rt I I i I r rtI t' I t 1i r' ' l l l Ir r II1 I:tItI' t t t rro t.t t I r' 1: l l ' r , r t l , r r , . r t l r 't l o r l l : r l t r ' , , t 1, ' l rt t : t , : r t l l t i o r 'l l tl i i l r r l r r l i r l i r 'tr r ', 1 'r L ' i . t r I r i ( I | | | 'l l I i I l l r '. t,r r,, I I ) l t t l r t , r t t l , t l r t l t t rI t r r' r 'r 'o "r 'r r l i ' o tl r r l :r t'r r ' r l r r ''tt|r 'l r L l 'r i 'tl r l i r ., r r |.l tr l t ': l t r r i , r l r : 't I I l t l t 't t t t t
I r '.1i , | , r r r r , r ; , t rr I i I il\ l l l l :l ,IIII||||III rt 7 : I I : I

:i i !

,",,,,111 ,iij.i,:jl'i;l{l;ll;l',ll:l,lll;; Iilj;,, )ll?:iliiiiii,X,t,,1ll:il;llll,,,,l;l;,,il,,,li.Jl """'li''il,l,1;,;l;;,,:,'',:r;i,),';,,:),,,,,,,":;,:,i;f1i;;-.,!\-df;llll'":i


r.4. pfioBLEME Dti DIAGNostrrc INRPATOLOGIA SISTEMHL0R

rrrttN tl t,i ttl itt P rrrl rl i zl rt (Hlu ll Hr , luilt ilr , r r r r llr illr l, o r r lr , , I I 1t ir r r r iI r I lt 1 lt f cllilol. trl i r' ,l rt{i l tr fi :rzrrIi l o rl c I Irr) . , \ t r csl, cir r r lr t lr r r nr r lilillr lr , xr , lr r r lr r llzii rrrrI I I,i 1 l)olllo Ail)lt(jiit, foarto oxaal, ftt rrJtrl()t'ril pt[.irrrot1' r'rr,rrrii rrltr i irri l,.iilst,r,r', l rr:ttr.l a l i nri i r. ti i ne[ fi z iolr gi|r , : : r ) , {r r l, ( . r . ior _ 45. ; [ r r t ( . t I.i : I , r , r . r l , r i rrl cr.i or- 50" ; d) inf i, r olr r zir l : li- , {0": t , ) nr r zr t l _ 4. - , ". Bl I.i.miloreo ctmpului d( not it0lp ;tt pt.;t)irea,bin<,t.t,la1i.:-p .1i,. , :r rrr ctzul in care ochiul sdnii,toseste fixator, del afecta,t va suicri lirrril,rrir,a, rrri;cirilor in maniera indicatd, mai sus. |n cazr in care ot,liul lxrllrrv cnI'c_fixator, o-chiul sind,tos ya prezenta o extind.ere a cimpulrri rlrr Iixrr(,io

iu,.tlircclia ,,liperacliunii', miqchiului sinergiccontrllaicrl) ,clrri lirrI i \l (Lal ,

;,r"*.rm,m :if f *liflri,ilffi if i;$tiFrl fu",x[


,riri;r ilft{i,:}}}"{*;1$

jiilililtf t:flr.rriffi'ft;ffi ri ld'*f T-pfroq:*ffi jiri'i,r1ir,J'llidnilltl[lFt*l::r;i"ilr3rp;;1:;i*:""*r::


jinrl:ii;rril{}1l*#il}:ryfffi$il,r1if#*#r,lxrY iiil
jli :ili ,,,,,' l,i Iii;,n:Ttj"i,{'fiii1"fii. T\;:ii,,i "il lx."lljy,, ;l ilil:lixl

i';ffi **l,-;'pg,f f *l*fftl',i"lffi ;3Hl*T.1 jiril"lr',',","ff j$ti:p1r,ir"*:r

Cl T.imitareacfmpului rL. motilitqte oculard,coniuaatr;. 11,,1 ilillir'll pxpjoreazl prin in.pccla.rea-ex"curslilor volun rd sc gl,biLr| "'rrjuga.ld or, t3rl t0.col]lItzlle de p-rivte in sus, in ios.la dreapl,a5i la stingrr, r Ir.t.r.rIr ,,i lil solicilarea bolnavului de a rrrmdr"iun obieci caic sc dcilnii.lzr'i ir, rlivct,se direclii: orizontal, vertical, oblic qi in plan medio-sagitlal (corrvrrr. r('nt{ ).

r' i iii:ii: ;i *fl t +ury$ffi*ffiffi ,,v:" : ,, ,iiiiit i,, i|'i,::,*i#iilii$#*:#11lt *;,; -iii
' 'i:',ii;lilr'u*l,,i ,ll1#i:i''',1fl' ll;iil;ill'lx;'' d1?"iih:,,,"',,,,,'
I. l.,\ttrrl irrl uotilildlii, , . :;..t. l0

Uii:i,ii*i**i$*,ii,;'tr'{it'1fi;,'{#:ffi{f;;i;g$

2.4.1.2. El utliul ntotilitd!ii canjuoole aulttmal ico-refletr utilizcirz:'i rlr'tli procedee: a) Deplcsareain cimpril vizual a unui obihct-1cst lumino*, ,)l'servindu-se ulmdxirea acestuia prin miqcirile globilor oculari (,,tloll's lui ") ; b) Modificarea pasiv5 a pozil.jii r.apuJui(maLrr.vi,:r. ''\,'..movements Alrjou.anine), la care subiectul arelendinta ile a'-simeirline globii ucrrl:tri Itr pozif ia ,,primard,' (,doll's bcrd fenomehon"). lisifel, ia roiarer crrprrlui rtrre dreapta, globii oculari tind sd, rd,mind,in pozitia anterioa,r,ri,, ori a,ll,o , trvilie, fali nou_a.pozilie a capului, .ror privi s'prcstinga. l_i rotirr.rr. .de ,'rr puJ ui spre stinga, globii oc}lari r.or av"tr,o ,,p-ozltrlc rielativX': splt dr.cl;rlr,. Lrr }tiperextensiacapr.rJui, globli ocrdrri vorliua ilozifia relaliv infoririirlrl, r:rr' l[r flexiulea .apului, aceslia ror lua pozilia rcjrtiv' srrlcr ionri. Ll| llr(li t[trea capului pe un um5,r sau pe celdJali, sc vor produce^miqc?ili tonjugfl,t,0 tr'llr'-tccu ca^ra_clcr ghaior, in sins orar cind calui csm aplccll spo rtir.i1l.rr. rl,r ituterior.cind eapul aplecat spre stinga.^Seva ruriri,ri qi cirmxrrr,ll,ir1, -este rl|llrre Iimrtalea ml$crr or cojrjngxl o r.olullarc 5i rr.fle:r.cu rri.t:rgllrrrst prin cscitarer labfujtriiciprix teslcl,.clnsicc(rolltor.ii,lc|rrricc). ;,r',rvocai

:,,,:iii:,:i[,i,!!i:,:ii,i,,,,:i,,ii,|inri'i:i{;*|;;,-*,1,
4t

... ?:4.1.4. Stud,iul d,erialiei paralitice a globut,ni.oautar (Strati.smul, ). slr abismrl se.exploreazS,urmdrind pozilia "globilor oc.;ula,ri ia privirr:l ln lllli.Di 14. priyirea in toate dil'ecliite. Sr.&bi sial 1sl.ratitic(tlctutirit,1tn.rutr,.,,tni,tent" ).se. ca,racterizeazl prin laptul cX sc acrentncaz:i,1xrrniitrri, r,o l,rilrr:wuliqi dirijeazd,privirea in rlircitria, mrqchiulni fl,Ileota,ti. i,ukrm lnlilli trltrLitoarIetiprr-ri de strabism a) donr:ergmt,prin llaralizil rnrr6chilor llnlrlctori; b) Diaergent, priu paraljzia, nli6chitrii: atlituctrx.i; o) iu1,ru tt ticnl. (.surcumrergent )1 prin paralizia mrrqChilol colxrlll,orj ; rl) l\lrr.,tt tttcttr (subsumaugcnl ), plil paralizia mu"schilorrirliciilot'i. I$to necesar ca strabismul (cirrd rru es1,o }r'ca cvitlcnt) sli,fi{\ rf)iilrr)inl1 rrlif.lrrin testuldruia!.iei (.1t silliil(}$), ltrimtrr (eincIurhiul-Iixl.tr11,ca{6'1,,.1 rri.lrrin lesiriZ detialiei secuntlare (cirxl ocliul rfccl,or cstc ilralor), ovtr:riul,l trf jliziniln-so Ei p arirnetrul, lu,i I' i)rst.er.

2.4J,4, Iiwmin-qrca pftilid t'ottt1t tttsrt ttr i I a MInl?ti,ri rr gfirrlrr.i, 1.irrr t t ltltta du rcguln: ,,boln:lvnl i;i thr<r'r,ltprrl trrolrrirrrrlclrt.r,ri'lrorrtir'rlit ,.ltittl pu,rolizol;tt, ln lncolctttr,a, ta rl. it t,.,nJ,(,ltHlt, Itttrrr{rilt lrtt4rlrirrltt

, \ t t llr' 1, llir( l{,lrllll rilr l) r t it lr t r ( ' lr ( il( f c il, l) ul ir lr l r , r r r r l i r r r r l r o r l r r i i l l i t tl i r t l l t l ltl r'rt ltolrll trtlr r r r oc lr ii. l, r r lir l, lt oz ililr qt , l l l x \ 1 1 1 q 1 t . 1 . 1 1 1 1111, . li i l r, l r ( , 1 t 1 1 11 1 ,,r.ilqllli, i] rir rr l i r i (. (lr1 (l1 1.l,l, rl\l,rrrt t i t lr r 0lt li. i ( r s t , o ooit 1[ 1r q l q , 1 1 ; q 1 1r1 .r ,rrprrl rri 11i lr gilltlu i, r.rrrrl jz , ir u[ - - r uini os la oopii rrslrr.r,l,rrl clirLirr rj.e , l rr I l i I rrlis" o{,ltlltr', rllr (1 ll oit I ir ( : ' l r edlr ( t ibi- l ( pl. ill l i | i i l lrl) stnului sau

r lrrIlrrr,{ici utrrlrlrirrlrris1cll,r t.leirlo-mestoi{lian) lRiior, iOlZ ; Aneni 1i lo lrrh., 11)67 ).

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1.1.1.5. lltumenul d,iplop,iei. Diplopia (perceplia a clouL imagini alo rrrui sirrsul oltiect) apare doar in leziunile oculomotorilor cu strabism fiind absenti,jn strabiBmele,,concomitentet'.De obicei, ,rIr,or0orni1,otrt", rlisliugc cu uqur,in!d,,in majoritatea cazurilor, imaginea ,,ade'olrrrrvrrl 'rilrr,lir' (rrdicii,cea,perceptt5, d9. o_chiulnorma,l), care este n15, imobiii, Si rrir.:r.nr.rrr fi pozitia calului, fa!5 de ,,imaginea falsd,t', care este mai puliri llrilrrcii,oarc, mai pulin neti, d.ar mai ales mobiH in raport cu deplasXiile rl iv irii (Iiisur. 1952). ln diagnosticul $i tn interf)retarea d,iplopiei,trebuie si se tin?l seama lrr rrlrrrii,l,oart>loprdncipii. (Riser, 1952 I Sachsenweger, 1966, 1969) : r) Irrirginol care trpar{ine ochiului afectat (imaginea ,,fals5tt) estetotdea;una fullirrcrrlrii il dieclia_ de acliune a mlgchiului paraliza.t,, de piltl5, sprg lrrr:r,1rl,rr, strbiectului, dacd abd.uctorul drept este in cauzi, I b) Oaracteiul [r rrrobilitlto estc deosebit de important, in sensrt cd, ,,indepd,rta,r'ea" r,|,rl rkrrrii,Lna,gini este mai mare Ia dirijarea privirii in direcfia de acliuno paralizat; c) Oinat privirea este astfel diriiati, incit.cele rrrrrrichiuhri orrl irrrir,rrirri $int indepf,rtate la maximum, imaginea cea mai perifericd) ltitrc ochiului afectat. lrrr mai preais al iliplopiei se practici, testul d,ed,iltlopie (al, . I)rul,nr, sl,ud,i,u,l li(lt i t.tlotul.(). Acosta se ofectueazfi solicitlacl bolnavului s5, fixeze gi sd, rrrriirc:rsri trrr ltr.ivirea (capul fiind fixat) o sursd,lumitroasd,de mici, rlr'rr$il,ll.c(tlir,crirl uloi luminflri) rDezatd ]a o distante de 4 m. Do rlilr, i r lr.( r ,rr,hirrlrri drept de ptascrzi o sticld rosie,prin carc Sursa rrrrirrorrsii, rrltlrc coloratri.Apoi sursa luminoasS, va fi aleplasati, in directie lizorrl,rr,ll, v(x1,i(n1,1, ;i oblici. Bolnavul va relata pozilia qi direclia depiaprcc[m qi distanla dintre ele. Una dintr.e imagini (fib6 irii irrrrr,ginilrr., rrr r,rrsir., r'r,s|i'ctiy cca,falsf,) se indepi,rteazi de cea rea15,mai mult sau rrri pr(,irr, in l:urr(rtie de direcfia privirii. Astfel, rlistalta rtintre imagini , rrrirrrrql,rr 1xrrnrisurri ce bohavul pli'veqte in ctireclia cle acliuno a mu$tirrltti lt,lirci rtt. po:.,t,(',li (produsdde afeetareamuschilor ztbductori l)i1rlo1rir, ot'irontdl.d rrrIrIrrrrIoli), (prorlus[ rle a,fectareamuqchilor rialic[tori sau rertica,Id, rl,rr|il,rrIi) ,".ioblicii (ft!1. i,8,9). parte cn ochiul afectat vorbirn l)rlir inrir,gilloit {alsri i.lparede aceeaqi o d.illtltic (sau, h,ononimd, d,i,rectd, ':ln'o ), iar dacl a,ceasti,imagine fal$d, l, l,lrr.:rt:r rh, l|rrtr'il (x.hiuluisADitos,volbim despreo d,iplopti I helero; tt,,r(s,rrr itt( rtt(iyti ).1n goncral,itiplopi* homonimilsc a5oeirlzil c utr nrlrirrrr corrvo!'!loril, i)r diplopia hei,eronim,i(incruci$atd,) - cu 'ut stritittt rr r l i t ' r rlgott l.

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Fi?. 7. lnvestigalia unei diplopii priD paraliziea nelvului aotor ocular (xlfr|l (lr('l)l' ochilLl sting fiind normal:
pc'e relr'znkli i' llnii 'ln .StiLla r6ie s-! Dllsl in fdta o.hi. ui Prrc ?d lnagnra @lorait F tufL l mJ 8 i ' e a ro ' i e s " d P p l r. e ? e rr a l l r'', n l D u l r' s a " o d i i ' l P n h o mo ri n c onti nr ,o.Se i .r s " r v a'c a eLo 'oi u d Fl rr! i d h t l ' r' O ! (h i ! h l d F s a d Fa p i r, . d i c d t " n l i ' a l P a l i t i e Li r bol nav Ll D r i v es l es D r e D ar t.a P J r' 1 e d a c @ . i t a z j t i F d i E r8 i n i l . r: i , , d ' * " t i d e n u s d r' . l . r. t l n 1 i , ' l .tr r gar a" o i i ptopi e or i ani al A j ,n" i sre , . u pLn drPrfr3: spre lEvrJ' rn l -l r. i h ' L r! : $ f i r i . . n F a f rs rt d r" . ,Ac eea.ii nv es r i r a!i e,d" r ,r i ,l a ro : n ' . c a t l a i a . ' i r " , . rri ' n i -l rI l I t r Fi s P r' o 5 2 l d FP l " /

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| Iri 0. ,. 1)i pl 0l )i c geuc tal i r tl c l l l |nrl l z Ir IIrt drol )t i rrh' r' i or d0 l )l ttl rr rl f,.i r!trt. dri l l ui s ti rl i r rr)i i r s Il rs rrl i n l x l t r,fl tl ul l rl l l rt!l l l rl 1. l rl IrU i D ( r r ol i )rx l i i l rr rol [ (ti r!||c nl i l (:rl l i ni i ) s ,. i |, I)|r|,I,:|2n\l )tf l " i ' f. I r l l l l l IIl || rl rrl l ( r (1l t)ri \i |rr :rr i l l rl l ri rl n i [,,r\ tl rl rr' , rl r, rrl rl r ((l rrl rr ,l i t$rrl , l l l l :r).

l)( liltlii,: I)i,plo7ti,(, o|izont.aldh,unzon.i,mii poato fi prodllsi, do luloz:r, rrlrlrirrltri rllrpl, r,siorrrtltr l:r 0,IJ., ilc la, 0.S. s:lu do Ia,a,lnbiiochi. l)rurjl, lt,girrrlrsc rlo;li,r'lcuzrlir rLrlrIlts:lltl,srrrsci)utrrinolse slrtr (1t{.il,l)trit, (,sjn rrrl,rrl, rlllpltrl rrr l'rr rlrrilr,()..1). lrr sitrrattill rrol(,rario, tst,cnfocl;;l{r tlrr,lrfittl ([iitll,r(,(,i IrrrrrrL, I:r (),iJ. Nli,r'irrlr rlirrllc irnrr.girri lrr lnrlttrlrrxoir;rrli rlrr

|tg.8. Diplopie priD p:uRlizir nrutchiultri d]'ept intern, carc se :lIL'i llllr-ulr u$or slri' lrisnr divergent (sprc drcnpta). Stlcln fo$i( s{ rlld plasattr 1lr fnfa oohiului palrllril t , i l 'l o p i l l r 's l , r i | | c l u c i ) u t , i |r l i r tr x,r i ,rr' r1,lr)mlI iri roflt (tnrr(r1,fi {lLr lilrii ol)ll(f) nr. {ll)llrs(:rrzil slr(j !ttltlIrt, oltlntl rlllrl l),,1_ r I d /l /sf/, l l l s:l ) . 'r r \ r l J i r i \ 'f f l o $ ! r c r l 1 l r 8 n (

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,,, ii,,ii,'i, riiicr t' i".^;,,#ilX ;?d;L1'JJJ fr#ii:flf #friH rkfiicicnla .l"r, u t,rrrr.i. aparli:re mqchildr conoriioi,i, ia"-iaca distanta .rlrr lrr,irr.lintu.taspre in sus, este-vorbacle. p"";rt;;di;;#il;
lnr rlorri irrrrr,gini, prin inclinz

r .r, I:r slirrg,,. Sc sta'ilegte ciircc.tia dc A"pfi*.r. , i"iJ"i'i ir,,_oo*u

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:ll,rliliii;;t:i',ii,Jillll.t""ir.:'*-## ji,i":;:-..#,J,jljf ;I r

rrr,rrr{r,lr,s sc ilnlunc ileterm,,inarea. ochiuluipi a mu-;ctttului aJectat. Astfat, c vollrl rlr ochiul drcpt, daci, imaginea iann lrosle)est",ma, jos sau

mare sau dreptul irfe'_ rror pp de o prr le (coborifori a.i globnlui I n. .-r, * oc.ular) Mu dreptul superiorsi-oblicr ] lq p:. p.Irtc lridicitori/. Asrlel, .:....., I | --.rl1'!, qo a.l1,i orca_drptolrr I verticalflso lccenlrreazi, ,".... I /_ | r!rs. hdh I iit".rl lO la ridicareasurseiluminoase(sau1aritti_ carea_ capului), ochi l fiinal in adrluctie, muqchiul afectat esteobticut mic (/2.q. JOjl dcpistarcapdrtii paralii1,i",oi_ llntry tarmo,ogrjDbtlizcazd" si prob& lui Eottrnannqi Bielcho.n-sky : dacf, indepirlarer, imaginilor se mx,re$te prin inelinareacapului la d.reapta, inseamnd, ci, oblicul /i Ess pic sting este palalizat, ln sittratia in ,/--\ | ./h. carediplopianu seaccentueazi, in aceastd, o'( \ | /////An n -\ I I V/////t pozilie cleadduoliea ochiului,estre \*.. vorba Yal de paraliziadreptului superior (fig. l1). I Daci, diplopia se accentueazd / r , l ,i l rl r, pi(i $( f n * r r I I d c p l r r a l i z ia la cofori_ ' h llll ,ri l | ri( r)l)ll(:( s obllc inflrlior) lea sursei luminoase (sau la coborirea , I r . lrI rl f . I t ii, (l n r c L l n r D a l t r o r m sl capului), ochiul fiintl iu arlclucl;re, r r r rzn{l i , lrrl r)r: u l r t rl n o L r i r ' [t l h su s. rnuryI r ',rl i r r t l lrl s lt l I o l n [ c d o d ) t u lu i chiril poralizatcsteoblicul maro i,11,,g. tZ ), l l/ ll, Ilrdf l)rlf lrlr o l i n l l r ; t i l l c o lo in sohimbrlacii,diplopia nu so rcoclrtru-. r1r lt, I|l l x lI lil nlt r t r ( : l d ( l b o l u l v u l , l lr ' l I M t i irzil jn lcou,sti, pozifio, a[unci lllul1(jhiul I l i t I r ' r \ I g n ( d t r t) { r' r. , /ti 11)5.t), rrsl,o rlr0llt,rrl Irrrrll,lizDli itrl'rilior, _ 1 I I

,, I --T-----l b, I

f"?:,iff;"|;;H"Jil"f,,",1J"J;'"ffi,,f1 rerpecbi_v oblicirl

Jriq. .17.Diplopie generatd de paralizia rniEchiului drept superior de Partea dreaptA. Sti;]a coloraLl s-a plasat ln fata ochiului paralizai. Imaginea colorate se depiaseazl snrc in sus, cu atit mai mu1t, cu cit privirea spre ln sus 5i spre dreapLa' sc j e -lrii"azri p o i t c r e m a r c a . i o b l i ci l a te a i m a g i n i i ''oloiale spre slincu (dupi Rirer' 1952)'

m,, m,, ',o1 -o1


genrrJ Ld d. l ' rr rl j r i l Fi g. ,?. D i pl opi c . muqc hi ul ui obl i " marc (s ru onl l r s "Ir' r r(' r ' de partea c l reaptd, c nre h nl oti rror' rtl rrl j" ' depl :c eaz e gl obul oc ul ar In af' uJ s i l rr i rl i l i fnl S ti c l a c ol orati (l i ni i obl i c e) s ' i inaintea oehinlui PamliTrrt '

2./r.2. Paralizia nervului oeulomotor eomun

in cadrul paraliziilor perechii I Ill-tt' I situalii sen'iologice Existii,,srise ttrll slrlr rtlir' (inconpleld po$iald .'t oarali2iaertrinseed ) cu alectarea uJr (cu rfr^r'lrrt'r completd' ertrinsecd rl,,itir." . o..tili u:.irinsi"i iil p)arat'iziit' (cu aflctlr'('r' ilr'rrr i rt\rinsecdiri*""'*t*ilifi" ;'c\ Ttaralizia ""trinsi'cij ridtra rei : d) paralizia totald'(cu printl"l'rr :rlri ;, il;;"ill*ii ;; pilocor'st intrinseci); e, r) irt mllort ctt.frr.trr'i qi, &iGi".i.ii ; ;;;;;;i;ii sau bil'axatatd "*lei poate fi : wnilateraLd' p6tn"nii a rrr-a i;;;;"s;;;;;i*iiri"

ilmpliax' o-.ptond 2.4.2.1. Paralizia tctald' a nenu'lui oculomotoraomtLm ilo a'o{iuno a dirocliilein imobil glob ocular oo*rrieta ;i un jos fi ind tol'ttqi itttt triu ""f""fr"aie (mi;ci'rile inferior arupi i"i"t", ati, i'rr(.rirr"" -".ii*"i bbuc-mar'')|i drc'prsulx'ri'r rnuqcbiului ,:ii*]"p"!u't" "T ir";" St:rabi.imulttivirsent csbe foarte'evidenb, irr rliplopia cste orizontllfi ;r ptpita este midriabicl $i ,,fixa", nercacfiolrirnl lr lttmitrii i'"i"-ii*i,. Ir! flcomodare gi la converAoo!6.

osl'o ltlllll a nerawlui ocuLomotot coT'?lzzr, 2.4.2.2. Itaralizirt' parliatrd, 'corirplel,ri. tttltttrrrtxt cil' fllrl'lll rolinut l)iur trcbuio ,no,iireoventl ,fecit oca lrl th'btrlt incompleL (prr'rlirLll ulcc Irtin nl,rlrlitrl i,,itriitil .lir' prrrIirrlort p:Lrlrlizii Ar:r'sl:r' ",,i"ttt,ltr: I'ii .,',,,u i,i,,..r.i""ii. ii,:'i"-i',,i*ui 1x'.'t 1r:rr:r'lizici' ll),nN $lrb srt'tt rl'rtrttti, ;;;;;ili,t blli,i,, s,,h t'rtrtil llzitrtrii 'iinoi sing.r. lrol'vr)lr' rrllllltl'i rnttll,,t tttr!i ttr tl.rr rlo nrlr*rr* iiii rr ,,*,,i,,ii vrr,r,itbil. ^f(nJli[,tr) Hrlll l'lrrll tl ltit'tozohtt vrrrirllriLl' tltl iltl'trtrttltt'ttr irr,bl,rrrli il,i,',ilii'li','n,, '',',,fizol,zr1,

l r,"rrl. r rl. rrrrrrl.lrr rlr, lr l . r r lr ( l. t . r ' , r lr . r , 1r i ir I . r ' i' r ' , r l 'r , 1 r l r r r ; rtr rrrlr| trlo r' l:r Jrlr"rl r lr r . r I I t I , r ' I I r I I ||( , . : ' . ! : ' ,:.
t lt t t t t l l t I

rr ,,lrlr,

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:'.1.:!..;.1.I'uruli.,:iilc lronculare itint ijelc tn:li lutnet,oil.se, in specia! |rrrr :rl,,,ii',i (.11t.se (lezvolt;i la nir,elul bazei craniului (J,hnsi,ori qi l'r',1I .lollriou, l1)6?i liucker, 1966; Riser, 19i2; popriviciu li l?ascu, I : lr;0). li. rrrl r'li'gc ilrt,rL]citnerYll ocu]or:rrotor cor1tunp:i}isoqte tt,unchiul 'iL, ( f'r',1'r'irll)l ir li) ila$oioulc, leziunik: ,,rad,iculare,1 lil accsl,rrivr:l ltaiizcazL :rl,. i.r'i l'lltill(' si irLcuale alo muschilol oculomotorj.il schirnb, l.rrlte It ttt,tlt. lrr ',i.t,drr[, lrttttchiului rertos prod'c o ]tt.alizie lotali'i dc pcrtcho l l l. r u (,\(1{il,1ifr i'ibrelol pentru mUsculatura ocularii intrinse0i. care ..ri. l,r( o olul'ciite protectie specialir in lozirLnile blza.le.ltrin ;i:rptrrl r':r r.lr. 'r'rirr(lc rr, rrlli silrrLl,trintr-o pozi!ie arialir ir.r interionrl nervrrhri. doar
Itrltrtlr ttsittntrr ittltut't antirttd plotlucintl 1l r , l ri ,r' liliigilr r , 1! ) 50 ). a.fectaroa pfr,(iorrr lt llce\loI[L

'' l.:.'.;;.1.1. I)u.ru.li''"i([rcnrcttlard izolutd, singu,latri a nrrvu]ui o0.rlo, ,1,,r' (l,r''r p,rric lii r.r,aliza1,ii do procesc nevritice, meningitice (iriclusiv lrrr,lrlr'), r'rrlr,ori do alie pluceBe bazale (dupii culrr rom r.etlea), ri:r, de olrrr li, lrlirr \'(rrit)iilit1c1llcestui terv cu ceilalti nervi oculon$tori fii (,n'tlti rr, r'r r r.ltrrriIrri, sc rt'lllizeazI sindrolrne tt.otLctrhrc r.-\1r.ilrre\"r,it,\in]e ale. l, rr i ,, ' r lt i; r li r lr . r r , r' \ i (.l ttri ,,r.i . :'.1.:!.:j.l.:.'_,\inrlntu,utt tronc:ttlr.r,t r: entraneuoJ)iale d,c It::i.tttti rnullifie , 1, tr, rri l nr t ir , t r i ( r u, r:o i n l e re s a re a s i a m o to ta c u l arl l l tl i {:o.t,tu,n,): \t ll itrtttrr, oIt rtl..tn oltk:aiaii- Se ltie ci, trunchiul lerr.rilui oculoritotor. i.,'||||l|r \rrr{l lrr (,l|lll,lt(,1] (1lt 1,r'ei:ulcle (:uttCra bazilar5, a;r1.era. cerelir,loaSli rrlrr.r'rrrrir ril ;uJr.r'l r,t'r,r,lrlal:j llosLcrioari). Aceste configuleirii topog.allice t , r'rrrl l l z r lr ( ' ir r r r , r ' r r rl rrij rr a rrc r-r,i s me l c q i i n p ro cesel c l j ,ero- sf al teri oI l "1, ll, ' ll'. :l. l..t,rt i I,.l' .. n lir s( . r ,\ir li( ,1 ,t n ti,trntttr ,,:! rl rtt6ptl l i

lrlr ,,rrl r l ir r ir , r r l r r nr it .r i ri c v rj s rrti ,rrl t, e c c s tr,rr' -]a " . .-l U i gr" ti ,,c,ftai rni pl egi ci , r1'.,r'r.r|. ,lri.r'i irr rr.lriliilio sa,uadolesilcnli, (tiickerst:iff, 19{l+), lr, siiliiircti , , r',.rrrrrrr l, r , r . r jt ' t r llr t ilig ro tl o a s o ,l i e ta m i l i a l e , fi e p erson:rl e. I{ i gl en:r, oftal r rr, ,| 'l I r, rr I I ) : r i( . s ii l11r ' t,l l (fz 0 s a s l i r n i ' m c rz e rl u p i i O n i grel ti si rnpl i . Il nrerOa , l, l ,,l ,l , r r , r ir 1r ' ir r r r r l s i rtrl rl ,,rrr.l !:.r r,;1 c u n i l a te ra i l , cu i ol l l i i z:i r.e or1;i i i l i ||r ;r,,rr0r I r i( I r I iiI , i r , i | l td j 0 ro N l ]l ' { rv c tte x , i l p :rrc c obi cet 1l r cri zrl . cU il, , l,rt l ',1 . ( 1 r li t , r r t . r r |irtrl ,u . , s rl rL r tl cr gr..r1,tisi r-i i r' si i tul i , iu l tu l s :ri i l , ,rrl e s r.ti 1, , "r,. rr ' r I l J u l (...\l r,-.1 , fr o ,.,.t, ,,,.,,,,,i ;1,,,. .,.i rrt,rz"tl :1,r. ' r ( t , ir . , r t , - , , , l. l ,l ;'i r., , ( , r r ) t r r lilui( ,l i r:rrtrrrru ti rl s i r0 a l i z o a z l -r, .te l mai fr,({ rr1:er}t o ati gcre , r rrrrl rl lr:r-: r I r , r ' r ' r , lt iilr t rl l .rt, rc s p trc ti ri d u n c o ri i n e l vl l i i ti i :r1.r,i nseci i .l , { o, ,lf l, .:r l \ r r . i r r 1lr r , r i rrl i tL t| r.r:s ti l ,0 rn u l t n l i ri l l t,, ai l csi rt, i t.rl soci rti | cu .rlr r;,,.r'i :r 1r lr . r ' r , lr ii l I l1 ri . In rrn d c c a .z rrl i p o a i .c fi i n1,(,i (,fi l l ri , rrci .rul , 'Jl: rl rr( (\ \ ' ir lr lr r i ( ) r l) { ri r(' rl )., l 1 } (i l ); .[1 .l rr.< u 1 r,.. 96$). S -rrLrrl t,s,ri i s l i rl Lnr:. r rrr r( '" r':r'i r ( ' 1r ' r ' r z r l.r lt |rr,i p ri rr rl i Il o p i i 1 r,t:c i i o i :r,t rr , l .l i l i i rl rucl ' i , sl Lr [0r,i rr0 rrllrrtr: rrl r., r ll r r r ir lr r . r r iri i rn g rJ i 6 i ri ri ;' i r.r,rri o il l :rl rrroIl r,i ri ti (l l < l l L:z5i S ol l rarli r, l l l ti l, ) - , , \ li' r , i, r r ll l rrrr,r,r' i Irr ,IIrrr| o rIrl rIrrl rrr. i I i r[r1ori l i i rrrrri l rl rrrr:l l i r ' . u, r ,ri o l l {r r ' \ ' i, it r Llr r ic rl rrl l o l j rrl l l r< ri rv t,r' i ro s l l,c l ti i r.rr :rt.l cl r rl rrrrrl i tl l i rrl, 'r'''r, ,,i ' r . lr ' r ' z r r r lr r lr r.r' r.ti irl i l :rl ' (i rri .rIr,rrrrrIi Irti(\\,:rl rl r rri (),l rrl ri rl r,, ll) t ; l l t. 4t l

.t l i n

oftalmicdui, reflox cornean abolit' dureri in teritoliul llorl'rrltri rtllrtltttic. Daei, sint a;fectade$i fibrele simpatice oculal'e, apare o ltiozti ltrritrIIItctrIrrIIi r1e cocainii. AceastS, tr,iozil ne indici, respectatea g^rurglionul i t'ilirtr' ;i, r'rr, Dimpotrivii, aplril,ia midrir.zli rr(' rrltrrll^ .afare, o lr:zjune exttaorbitlri. atenti:i rsllpra unei leziuni intr:rorbitarc, ct lldecta}.eafilrt't'loi' rh' Lr tl:rtr .Elionul .1iliaf. b\ Sintlromul de apen orbitd,l' al lui Jacob ti Eollcl sollmirri ('rr lrrl'('{rdentul, dar, lrin distrugerea soncomitellti, qi a giul'ii opti('t, s(' rtrltrt::;:io leziune progresivii, de nerY optic cu cecital,e Trrogl'esiYri r i^rtsolili'r si rlrr chemo$js. Dxoftalmia estc mai lrronunlatl'i, rlecit irt siiltllottrlll llt(\lrtlltrll .qi pulsltili, {prin comprimalea $i a Yonelor olliiillnicc). Iractorii etiolol\ici care irebnie dccelati sint : (peJlLllr sirrr;''ili.' iriterven-iiile chirurgiotle - L-actori traumatici: .de exernplrri ; fractruile (,ralu'cnL' care intercseazli' ii orl)itn: lt:t|Itr|ilrr .aripii mici a ,ifenoidrlui (cu afec{area ini.tialil a lel'fclililr' Ill ;i l\'. rlrlr ultelior si a tligemennlui - Rollvet' 195?r citat tle Iloger fi ('trlrrl), ll,(il)); ollrultractura crtstei supraorhitare (in aceasiin sittatie, oetit:ltcll lrlrr{,trtl{' m0piegi:l). neoplasmele orbitare i tnclliltgioanlel(' ,'ii uli,r:rrrtllr' - Iunrcrile: eryului optlo: t, Inorile osoasc (osteoamo' rnot:lsl'Nze osoils(r, llllriot'r rrrl .ostcocla"cte, chistuli osoa.se) t meningoencefllocel ; clistut i tlt't tttrtirtr'; lrr'li prolifertitiyc dt sistcdr (grilluloame eoziuofile, boala, llLi Ilittll Sr,lttrllr,r' (1(ltttttot i rrlr' Ch'jstiari, rrieloame, boala' lui Ilodgkin) ; turnoli tle l-ecjltiti,tti n:tzol:ll'ilrgi{fl)c, itttlcosr'ltr hipofiza.re; tumori tumori r3inusuhli sfenoidal, arcinoarne rpki{.xmoide, limfoe.pitelioame, hemangiot^pili:lirrrt'tito St t tt i l'asarl si colab., 19i5), Aceste ultirne tumori rlazillc 1i tritzolrrt'ittr.1t('lr, pot lenliza ilttii si'ndronu,tr cleJosi Ttleriyopalnl i n i al I rri lir ht stttt siutlt,,nul. ,tl epl an\eu otb i. t $ d, lllt i Dejer u, in clt o se r cllizpuzr - rit t ii i r I l. zit lt t r r r tt t ct t t t lt t r ,{nlrilal superior qi a non'ulrri clnalul[i ]ierjgoi(lilr.lr (li,rxct' 1i .olrtlr., m {- : t asf illr ir {}( t r t Llr t t t t r , ir li' l) lr 'r 'ir r ! ' 191ir ) ilm or i q. i colab. , 1969; S ri ni vts lt ; 'ntitlntr sau Df[,siallc l. ; - tr-scli,ii l\usclllari: ltner'risn c]; iingiolnxr (ir spi,ciirl crrr.l ttorr'rr') ti oI icc u:.esr caro t idir . t"r'. - Ll-ip crrt,'tee, cu ale1brtilat'orlfisulii or'bilnlc sttpt't'iurt ttJ Sintlrt'tnttL in.fracltnoidian al lai I)rtwl.tl st' tltl'rlrrlotizcrtzit pt itr rci un0l o si n(h {) r }r ului do all\ ( n: l) it al, dt r cslt l}r {xlt ls ( l1r lllr / r / r ilr i! r r , < d.t.tl tt" ei , catt) lillo ilf iar r Lasil, Llllt iI l piir t ( f ir ,lt lllt r l'ir ) lllii r r sit t t t st t lt t i( '||\ r '||||) r I , r.l rl q t,r1t!:a,zr i lllr t t l'izglt tr r lit t oit iir : lr llt lt 'iolll( f ( ( l( t t lll( lc l) l( , \ 'ilr ( f I I r' | | | | | | | i I t '|| llr l r 'r t l r t l t ut t t t t lt t lt t i oI i ir '. r:j rrh' orri rrl tri)f r i Ff r ( '1, ( r l{r (l ) ,S i l //r ') / / / ?f lt lt r iislt r t t l. ir '7'1l1ttt. l7: noidr t lii t t l lt r i , lr r &! l r '- r lc lcr r liz: t l, r lllr r , ri r, l ,rl Irr(| ti cu lr t t t t r I t lr r lt lt 'f lt t r ' llllr lll' lt r l] lr r r ii, llI it t zr ) lr ir r lll) l lr lr r ar :,rrrri ,tr sl i ' trrri tlr r lr i. ; . islit t |r r l, 'lr llll't lt lllllli. i{t 'lt t ir t lolf iI r 'sll. r ; it t t illt I t ll r ilr lilr i) lll, lV r r i \ ) , lt r ' I 't r t r l rl ,, l rl rl r , 'r 'lr ilr r t ( l, r r t t t r i r r llllil) 1": 1r clllI t iI r 'll, ,,rrrrl

l i \ l l r t t t l r t ttttr r l r l r ' l tttr tt,r ,,r t'tt,ttt; \ttl ) t't i ( 'ttti t ( N tttt r l , l ,ttl r t :.1 |tt,,i i 'r l i ) rrt tl I t , rrt t t t r' , ( l l l l ) l l r r l l l r r l l l l l l l 'i l zl l ( l i r ,r ', t' l l t t . ( , l l i / r 'i t z r i . r l r ' 1 r r 1 r 1 ,r r l u r r r l l r . | o l r r l r . " l l ) ( i l l ; l i i r i ,l . l l l .,i l ) : i\) fiirult'onl1ti. t:lu,si tlt l,rttltr. x.ltttrtidulii, rtl. lui lirrhtttt I)trtir1ttrurt| :it' c a i t a {r t e r i z e a T . [ ]xi u 1 ,1 '( ] l ) l r l r l l i zi l ' l l ( l cl o l 1 ,1 |i l l ( l r vi o ( 'l l l 1 ]1 l Io i ( ni . i l l i r i L l l i r l ( ' Sc r e :i l i ztl r tzi i : l l l l Ji l l 'r i ( '\( ) l l i r l l l ) i ( ' a f e c t a r ( 'a f f ) n c o n r i te n ti r , ti o l l a h u i o u l u i ' ( u q o l r e d u c l i b il i ) ,, p to zi , p a l p e b r a l i , o l ta l m o p l e g i r ' ( r 'tr vJo l r ( ,( 'IIIi II ( I) ||II) I( '|' imobil lrin 1lalalizia le.rechilor III' lYSi YI), trxttliticitri 1)lrl)iLrl!' (lirilril:i areactir.-i la luminii Si la acomodare), hipo - silit lnestozi(r itr 1r'r'ilo|irtl

4'I

:tr,r::i,:,1:;t,;,*,ii#x;!i:x*[ffi ffir:;li#j:P"*:Trl;:3:; l' tii,;;ll,l; ;t;t*:ll,*lt,ru til;,"l;l;fu".,?ftritlts#Hl;{i ^t"'ito"iuriliiifri".\i.ii Ff i" p""uri,ia perechilor I ;;..;i'ii ']'l1l'|fili*,1:"'n'*"
Eoger qicorab., 1e0e qideArseni qicorab., ,,,r,i,;j,:iill,JllI:i,,gl?j"t:

Lui .It'hrhn' | tllrli) H(\ It, Si.Ml,fomu| t1*.7t1 i'nauroytrtlirt tr ftrltrrirt l.irt'.''.ii' ';;;l,l';,i;i;'l;;'ll;;;i;Ji,lliii:l'lil",llilllil,"Lilll,ll,il,li:i,i,ll;lll ^;,,i r,rirlri, lii:,;/,,1';11,,,",n l)o l'rr,1rl,, 1,1rr, rt,rrdloxirr. rrta,,rio'rtri l'rlrrr), lll(il'') r;i l(t ll1', lll{il.; \V( irrlt I t) N iurl.nnn.ul, ilo ,nt

irr ollr!l ln('pl(!grr,' t'rttittrlt't'iztrttz'i1',ltl

j,lilil!lT:f;it*.1i{1'jx'H',",r"1,Hffi j?rtl# J:l:l:l 1r;ll"t*;;":nf,I;i


atecteazd,:. toate j;l ll;iilj;fif'l ramurire ,,,,,, "#:mi:

tr) t|,in.d,rornulanNeriore,ste identic cu sindromul de . fisurX orbitard, ri lrr,r,r{|lrrii, (cu coafeCtare& qi nervu]ui opU"l.'^--* -a tt) N,intlromul med,,iancoafecte?zd, to.,i icuiomotorii 6i primele rloud,

,,,,,,,,',t'1,t,,"'i,l,i"'i;'i,"0!,rll.on')
Ir't <ttori tli.ol,ollici :

p :ry,,,rr,,r,1,riirrri,li;l,,1if ?*1i"-?H1fl*T*1":i'fli*i"",S1llf fml*: seadaugr' d pQ'tro' l)ariantii,:

ri:;,r;ni;,**uili::,,J,ffi #i'"'#m'Fl:,-k*#?#i ;iil;litil;'li",ll:,T,1#**,ff


r rrrp | 'r.l i l i rr( | ( , r rI iic t ' im are ),

;Hr,i"#fd i'*1116*:f1ti*_T,%trf
sindromut' gtaratrise-

conmn (cu rorlizal,oa, a" r"r,f,l'r""i ori;, nroprosii lil:jl,l,,;iililli:11;lrrlui


t8

,t,,,,ur,tr,u:ale arterai carotid,e(Jeftercol, 1958; Arseni qi colab., ,r; ,.ri,.t ,l,t.u.t.t,Dtul.i,rzr :il c/c, incleosetri cr. realizarea de fistule . carotjrlo_ca.yerr,,'iu,.! r.irrt irr.rrriolrgis rtalizrnzdL rapiO : ottalmopt"egli ?riftamli puts:"tite r,r LI||||,|||I||I\ i,r'illonirrrlc(Iioger irl colab., lgOiO)." | ) 'l,nutlnfhltitt:le sin .sului caaernos ,tealiz(,azri : exottalmie masivd,, ,,ri.rrr IrrrIIrr.IrlrrI rju (,xtensic ftuni9 qf _p"" stare lfre rrr,;rt rlr,rrrir.i, p.rrvii, 5i Jcziunile ""gr""#iemporata, respective Ae ocrriimoiori trigemen. $i !) i.lll( lr.ro.ta,ea infecJi,oase : meningite t rrrtn, o.oiogite sifr_litice. ti) ltol.i d,o sxrtarz.. mir{om. multiplu (boala iui foft.1 5.*. t,',) tlintlrr.trnn,l da hemiboad, (sindromul lu,i Garaii, tintl,rotnul lt6 , tttrttlriu yi Q rrn:itt, sutt, sind,romultui io"tu realiza, in ..Bc.rtolotti-.Gairil,"i' ..rir,xl,{rl .lirriu rkr rna,sivll, Bi r:xtcrrsivi,utu"t""" ii" o".Ji;i,'ieni, qi p',ra_

tigt!,",",Lq; i;,lll l,,ll)(;ili,'ii,1,,,,,,".,,'*i*l,'iff-:"'i;"if,fl:x;"^'ii*iiL

lol:rlr., l!t(il)) ; b) ll\rmori rn

,,,,,,,,1,1,,,'11i,11:,T,ill,;il,H11i,f,l"Jifig:'.ljx"l?,:i"tfdeosebi "'anior,rin-

l"i $i llosor' l!)(ill; {lilrlr,lr',1 likx,,iwirr ' tkr Ifisclrot'-llriiAgl rt,Iosl; tloslrl'is ,r' t'littttsu,lrti de ar(xutltL t; Bi)mtrom'u'l' tl..r'i,ltrr <,ttttttttt (x)t'l)r.('Hilrrii .crvttlui (Lgiiffili se da;torc'Uo 'cltltttttttl,,t' t[. sltitl'itt (rxlrttr ,,i'castailivus'lui, ca urttt:iro , proccsclol hrloc,it'lr. ittsl'alaro rt' 1ta'l'rtlizit'i hematorir subdulat q.a.i. Succcsiunea -de "eiebral, lrritf iazr'i' ;-i unilaterali miozi tranziiorie ,,ste I I [-rt' 'r'in5,toa.rea: a perccltii l' 'rrpili' paralizie ptozd palpebrali' completi in final, fixd itt t"'ttt' Fischer:Briigi iiolo; a izolat dou5, forms clinic-e: a) lorma aau't'd', i naralizia ocirloniotorrllui este urtratd, ime4iat de pierderea o111lofliilrfoi itr tttrNI progresiad,, i,' Surn,n in care paralizia perechii a [II-l sc.ast.rci:rzi lreplar cu somnolenli qi apoi cu piertlerea cunostrntol' ' H1 Bindromul Iotoia-Eunt' Olialm'oplegia lir(sitrtltrrtn-ttl dureroasd" . o oft;n'ltnose-asociazii nosologic-5,.in catc entitatea reprezintd, tosa-gi*t) parte' Tolos:r (I9j41 a. tk'rctir+ de aceeagi pf"ei" o ndrratgie brigeminalS peria.rteriulc :rlo ritirrrrrlrri "u le'iunj itriimunfeeia, dur-eroasi la ul caz cu llunt gi colab. (1961) la qaso cazuri cu inflamalii gri ttrlo"r"otioini.-iut lente ale sinusului ealvernos' Smith qi Taxtlal (1966) alr folo$il' -rJomu de ,,sind.rom Tolosa-Ilultt', Ia cazurile care au lespuns tavoltltil iermenut ta tra'tamentui cu corticosteroizi. ln acest fel se pare ci' se t'intlo sit' srr fac6 o clistinclie clari, fa!d, de alte sintlroame asemdnii'toarc, diu'.citrtr tumoralo sau inflamatolii, care tttt ctrtltrltzii iini produse de'leziuni, in s1]ecial (Other. 1967; '\tilslcitr ;i [lottr'. cu torticosteroizi la tratamentul oromnt iio, ibzi; nnllf,lt". 19?3)' Lapresle qi Desi (197?) considct'ricii It'r'rttrrttttl ('!,t{) llll n(! tle'sindroin Toiosajllunt trebuie folo8it numai la caz*rile la etiologia' poate stabili cu certitudine Mai recent, I[unt (19?6) a stabilit urms,toarele criierii pclrl'm tLingttttx ticul tle sindrom fotosa-nunt : a) Criteriwl, anat'omic: deficitul tttrtttolttgitt prin leziuni la nivelul sinusului cavernos anterior qi nl fisru,ii "*i"-prio", ornitiale sun,jri"are. Structurile care pot fi implicate incltd nervii rttrttlo oftalmic, fibrele pupiloiilatatoari parasimlrilf ico tt l trrt'trt' l l i i *.io"i, ""ii"t a IIf-a, qi fibrele pupiloconstricloaresimpatice ale ple\u1Li lttlritlilttrl,irIirltt. b) Cri,t'eriut etiolioi6 qi' terapeu'tic: atingerea forrna{'iunikrr ilmittlil'rt csl'r' iiatizatA de un iirodes inflamator granuloma'tos oronicr 1i botrigtt, citto reaclioneazd, favorabil 1a corticoterapie. Cafuu,I'notologioolsindrom,nt'lui'Iolow'Huntloa[()1:irtstl'olsist'rrttt;t tiza't {I[unt, I961; 19?6; Lapreslo qi I}'''i. ll}77) : ir) rrl'rrrl itr I'trrltrrt(it 'i* ambele spxe; b) debutul mL ci'" lcciLt do ryirsl.ir (rlitr .tr1,iI:'itit' nrii6cii; o) (l('l)lll'lrl "nufl predominlr,rtl,l lll virsLtdo cu a VI-;), A""ua" it rrlo; (lo-?l lllloi llllrglrl tti;n1to ilaie fi nroelesiv, in citcv:l zile sau in inni tntLlto ()sto lllllll'1r olro rlc nai <xtnsl,rlrtt' debut ce1 ii,ota-itrii; ii) seninul (111 oontx)lllil'(rrll oftalmoplogici, 'Lrre're&' br-usc, de obicci ct clt(rvr zilo ina,ittl,oa' I oIl':rlttt'1llt'gi.i tItt':i itr:rlrlrtLtu' oaar*iu, *uu, iu rarc cirzurirll l,niirr lilrtlr gontrraL', r:tr.Irrlrt'ii' slirii ([t'buleazi :tli,,ralr'a air'ctiunea ;i-;;r"i Filr rnodeTAtd;f) dUrerea esLellnilAtol:llii, 'crlr.'i;itrrI rl{1t(gttlii 1r!rrlt)rl.lll g) rlrrorilo oital*ic, raroo'i prezonLin{f i*,rliri'. ilr horrrir:rarrju; qi. u'0o U)il'pnroxitttioo. oxu'c"arbrtrri ""i,o,"li.i urt sin't severe, cu caracl,cr contitnru ii :r,ti.,"r,nzii, tn t'ori do eurLsibilil;rr'i'. I trrllrrrrilr'i ll1r ou na,t iii^iu ao '5icri'ivo ttltxiltr qi ortr.''r{illtttl lrrl,vltlrri iirririf n-ffii-i",1lrri, urrtrrri hr i,r,r,iI,r,irrI li tlo rttit,itttttll,o h) olil,n,hnollogit, 1xrrr10 ir, ,*t .,1 rrurvrrlrri'lrra,lrdibul,.r; izulnl;ll, oxt,rl.n.cll, li,ti'g.r'. (liit rtirr r,rrzrrti) cornplri;ll, ,rxtornn I iiprii;i I

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lr:rrlrrlir Iit loltrltr : r lr r , r , r , r . lt t | : r lllt r ( l/ il r lr r r r r . . l l l r r r | r , r . r . r , : tt i l i ) t 1 l i r i l i" r,,r' lr rr lt \ | :r { l.'., r lt r r , . : r z r r r . r ) ; ! : |l. t : t ir , I r , ||r l|l|l i r l r r . r l , , , r r r I r , I , r I rIr. .riirr,,r,r,rr r' , . rr' t tr,,t ||r.rtIr)r r ||LI I LI I I ) |. I i i) ] llil|lir . r ! . ir l| | 1 t , . . I l I II(,I 1| r , i l . r \ l,l r]t / I I I I ' ir ol| t ]:rltl.t l:l', {lil ( , ir z ||r i) Lr t ; r |jlr lr ilir : r ir , l r , , l l r j t l t t l | . r i t l l l | l l r . t j r z r l rr. : rr, lirr .liu t Jltlirr |, ( , I I r , i|\ . j. r , . l) t 1. , r l. t t f ir( [ c lr . / , : l r . . r 1 , . , r . , , , r r ,1 , , r l i , , r r l r r i , , , t,rtirz: r rrrrlrt :r rlr, l|z:t t r , r r s ir r r lr : r , iii, , r t lr r i nlr u r r illl l r l ] ( , t , , , ', , r , . 1 , r , , , 1 r | t , 1,ortl,. ll rl,, ,.lirir 'l,lr lrlollr r ur I ir . r . lr r .I I ) r |r , I , r r lli. l, , t ll, ir , , , , l , l , , , l , , i i s {, l }r ) i r r {f r {, l l }l l i , t l I ilrrr!r'lt. :r.,,r'r'\ lilllj olt l, ic ( 1,. ( [ ilr , ( , ; t Zt U, i) '{ it , t g r l r r t , . r ] , , r , I t l l i i 0 , O u I n r N ; i , i i ; 1 r. : r . r l,itiiir.i rro ([ili( jir . ilor . I r r nt lr r lr r i dn oc hi ; lr) \,.S.lI. cste rirxlr,r,rrl ,

l fl ,,r l tui l S r,,i n r',.lrrr,tlrl'l ; S,rrrllr.irrL.r. si ltrrlpp, 19?3); n) sirr.pto_,ii" pritil;;;i,, -u .,rr. .:i;rr:irrrirri p(rl p.ozcnl,,-rbmisiuni spontan'e,- neori cu defit.it. .f,i rr.zrr rirrr.: (,) l:cnomcn.,lo ',: '.,,11',19,,,: pol .reapFrolr jnterval, dr. lrrrrl ' ,.i'.,; ll urn:tglr, slulrlntn:tlologie rispunde [rlorabil la ldmhistr:rrr.:r, ,,'l or){Urilr(hr-se unoo4 o remisiune complerd, ilr cil,ovrr, i,llllli::, i'll:'!il}, ,l::'.1:l:ljlll.rl j: :^lapr.es ,,1 \riu'c:, I ez tesi Desi.reTi);r) rtinprrrrr.r ., ::',,i::.1 ,'. ,,,rl11, r,rl'Ntrlg,.l r. .r. disculi Iie exislenla '.t Lmui proces i:rfllm:rlol. ,|| rI rrII Ir,| |IiI |,I)fi 1rs.r.l.t,urno,l .(IIallpikc, 1g73 ;' flult, iOfOl, ti" a ii,,,,i, -Clanhy irrurrilrrrl| cil Ia clzrDile. Aeicrise Oe-Uathe* Jtr,r'r',,r' 0l. {i ri',rr,r,"rrr:rr,,r,rsi:r criuici, a sindromllui rolosa-rrnirt poate-fiilSf intilirir,ir t I t (4 t ut ttt tt't r t ttt tn ) e care:,par prin afeCtarea aceleagfzOne topOUrl,li|r, ',, ilr. r':rr,{r lrrrl'ri. sri,-ldiferenlie-m,,ieqi a" di'iiiii,,f . 'rritrlurlrl lrrrrl,r,i """orie;t;-0.#Jit sfcnoirl:ile( iloctton_Duvigueaud) b) Si"O"omut ; lrrr ,r"Iri|,:rr, (|IrII'rI,) ; c) Sindroamelesin.sului cavtrnos; "1ru*ii, cLl Sintlromrrl rt,, r:',,lrrrlrr. (Jacoti) ; e) Sindromul pereielui extern al si,,r, rrirr ,,ir,y(,rtr)s '.i,rrrslirlr.irlalri .(lnrix) ; ii) S."l,lr.uryrt paratrig6minai al lui Raerl,,r,; ''ti'rrrIr''trrrrrrI rrri rr) sinrtromirrtle dff'us aiiui-r,isoner-griilrg,,. l) lrr ;rl;r,nr, 'rrrr.rrirxo; ,l.olosir,-Hunt, sirrrlr.orrrrrltri a,cirui etiopatogenie a 1it$l ri r rlrrl: rl:r rrlri srlri, o.ll alnoll( : fi produsii,'tit d. crrrzr, |to^te ..,.rl,.ril ll., r.rr ri rr. ,,^u"r,, r,rr!|]!o.t"t'eroasd

,]:l.ll:.ll'].:lril_ll,,.lt,,,t,rrlt'rlfla in unete cazuri ouilpr""e t"coriiri,.,iii ],,,]i,l;1,, .:r o o l ,.trrr.tj F a r.e n C io fl al rni ce '|| rr. t r , : r \ ' . . r . 1. o \

r l r ttItr r r r 'l l l l r l /r l r | Ir |, l r ) ( 'r r r t z r 'l r . r 't l r 'tttr r t Ir 'r i 'Ir |, ''IIIr Itttr r 1 r Ir ';1 r |r , r t t t t t l t l o t t t r t t u t r r t/r 1 1 r to r 'r 'r I r ' l r .r l r ;r r r ', tttItI|'It tttIt{i i t:t r |tr l l r tr " tttl t t'l ,, I|ir.:r|( ). r 'r r tr r r ' l r xr l r l i zt'l tzi i l i t tl i vt'l tr l i tl r l r tl l tti l 'r r x t 't r r l t r c t ;tl tttsi t, 'r tl r i l l r l ' 'l 'l tr ttr r l t:l si \ 'r r r - r l l l l i ( l ) r l I r r l I t r o i t l i t l l . s l t i t l O.i i i r ,:r t,"r 'r r 0 r r r r ,tr 'l r r l r zi l ti 'i 'tl ttl i i i , r t ' , , r l i t t l o l : t l t t l ( ' r l l l zt;i {) l l l tl l r l cl ct ttti tti t, l r l i tl l l r tr o l l r r g i i l l l l l cl o r tst" "r 't:t ''' ( l ( r l i i l ";, ( l !r l . , , r , , l , r r l r i i . . i r r r t t l l t l ttl tr l l ti ,,\tr i i 'r r i ;i co l r l b . ( 1 f) ? ? ) . U l t 1 IItItIo II1 i t.i ttr xr l tl r tsl r t ttr tz't l tl l l l i r l r t i r L r :ttl i l tr l t' ( ( ) l l sti i i l i l , fi o t , ', , , , r r l . l I i , x p l t t L , s ir - e csto ( iII * i ', I i c r l c r i r tta sta zc cl r e p r o vi r l d e l i l n t',o l r l l sttl ' l l r i l i I I I I | ' | ' i i t I 'r r : i : r t r , ttIr Ittr rr Itt[t l ttr " ( n l e tti n g i o l t p r i m i ti ve I r r L r ': t z i t t t t n o l i l t r i n tr a cl a n i o n i , ( 'l ( 1 ) ' l ,t'{'r l 'tl o 0 i d e l r n o j ( l o tu m o r i I t , , r i i r r r r r r , , c n r t t i o l i u t i n g i o a m e , '(osteoame, co r d o a m e J mieloame, silrcoallti) rrh' ) ('\r'rrcrri r t rrrrrolil<' ,,ru,t*,, 1,r'imitive

,.1:rl r., Il )17; lllhor nas si Yoss' 1970) . i\lrrllirlrrraiiilo \::lsctlai'e reprezintir d.upti, 'I'horla's fi \''(tss (l1l';0) ,1,r,rri trIl ri i Y fO 91,, iin cazr ui, m lar ea f r ecvenl. i a accst o}r t f iit t t l r t lit 'r t r r r lr r : r ller ir ism clt '. st t 1t t 'r t r lit r oir lict r r '' A rsr,ttj q; ,,i i 'ab. ( 197?) . bint r e acesi, car ' ' ,l , rl r:rl rl rri ri ,rl cs 1 a or ; iginea ar t er ei com llnicant c po'sbcr io: u( ',ll'lt lt {'ll{'r r zit ,,l t.rl rrrol rl t' gi i tl Lt r t r ', , , ise cu inst allr e r apidl, cu: r ; I oct al'it r r : t lr t sir ': i ili r r t 't 'r r lr r i ,,,r' rl )l (,l i i ri ' pcr' cdr ii a I I I - a si cu dur or t - : localizat L pe - t cr jf 'r t . ir ll ,,tt:ri rrri r,f[ri i si l se ir r soleasci dc r egr : lii t le t llbur iir i obit divo t lt 'sct t silr i , ,1,. .'itr.vr'istu'le inliiaclinoidjenc (intr:rcaverno:nsc) silli' reslt,trsrtlril' (,,pst'tltLrltItrtIIlItI''1, prop5resi'l' , , ,,llrrlrrropleuJi(ltllett)rt$o ctrro se inst:r'leaz5, tlttc lxrrtlr' trigtlrn-irrat'i nevralgie o ,, complt*il' oculolnolorjo $i l,rrlulizic ' ' d'' t r r lbr r lr 'ir ir t lr i. r r iir ' qi s, : , r com paniaz'r i r , f t 'llm ic n et vului l ,oi l ori rrl ' t, 1,:rri sr r t t . I isl t t lit r 1 ir li o gi: isi dolicom eg: r t ': lr r llar oot 'i st r p'r r r lc " ' " rrsi l l i l i l al c , | ,rl i rl o {.l l V r.r' nO ilSi. lr ( t r r r l'r 'zr ' ( ll l rrl i ' r1i i l c ol rt t it t ologit , r : ( : t r lest r l llr in int cr r n( 'lI iiI I ulLoi ! Lr r.:t,\:{,1,t,os) si nl sct nii, . lat c r lir r r r ir r ( , , . ] t ili [ ] t lf , ilrir L I iI |I r t 1t r t I r t t llit r r r l, t l r' j i l , 11ti i ni ,ti t t t ilr t 'r t zLi : it t lt t liil, , r lr lt t nt r lr r i s; l't lr r lr ' 1: r tit t lr 'lt t r ' ilL r r r r r r l i " ,l rl r.l (' j si nttzi l r '1r ',clr t t t ojt lit elc. tl(t t tll't) tt'lttttt j ''.1.:1.:i.:1. (i.tLt.ttr'tttttrrt'r:iu'lr, I'ara,li:iile rutliL.'u,Ll;t'e lt t r . zI t t r r r '1: r lir 'r " 1I t t t t t t ttItI0 inllla, r nLit or ii rrl i i l tot(i i tt l tzit lr t i vlt st lr t lit lo, ;i t rf Ir(' ri rri Ll ri 0r t I iblr 'lr t I lr t 'r 'r 't t lt t i i) |lllolllol, o! ( 'olI lll11( : ll t r t t ( , l{'t t l t r t r t t , rl ,r i rrl l l l l fi tgl i ; i ct t ! lt st ir ltt lt llt r s( 'llzilil'( f si t t lollir ii' slr llt ioiol'i: r L' uir t r r r : tl ' ;,, r, fl ri i rr Il l -l r so t r t r lr r |lr 'lcilzi ( 'll s( lt lllr t lit alt lilllLlr r ,t 'r i'l'lt lr it r t r r t ir lr r l"' r '( 'lt lr r 'lr r r il' sr r t t r lt r lt t llir t t iit 'i sct t zililI ii rr,rl l ,rl l r(' tl c l tttt r lclt l't lst t - 'ir / pr t lt r t t t ult 't l) t t t ( t t l( t lit t t t t 't lt lt t t l' lt r i ll r lnt ( : t it t r lr r t t nt r l' ,\l ,S i trr/t,,,r t t t i/ J t t lr t t t r llt t t t , il : ; t t '1t r t r or r lr t,,,i ,t' rttrl rl t ' ti t: ir 'r lt r r lt t t r t t l, t t . t r t t r I t lt t t i1t I r ''1i, ( ) : 1 1': r r r llr "r r r lr l11 t lollt t lll li , r,r u l ):l l rl l i zii' ilr silr r lr 'llr lii t lI I r I 't t I t t I t iol, t t ( lr I ll- lt t lslc lr r llt lr r lr t t t lr r r t 1,,rrrr rl r,,:i r,) 'r r' otrI 't I r , t I LI r 't 'ir IIr Lllr r lizill llt lt lt ii r ,l r.r rro tl l tl ot' r 'llt r l( '7il llii I il) r r 'lor I lt t li|r t llt l! r ll| ll( f i\ 'lt llli I ll r r r lt r r i" lr ll t i sr 'l: l( i r lr jll'lr , , i l, ) iiic ir r r 1I ot '|, I t Isil l ,r ,i r rI,r,i r.r, 1rl i r r lr iciolr r l ll( . 2( , 1{, ( , lllir 1. t ilr r hilt t l si' r ln'nt ll t lt r t , r |'r ; t 't i: i t t t lt i lr ll ' r li / r l1'r r i/ l l , l l l {l i l (' r(' l l l ,i i fl it t lt t ' t 'r i ! t |t lt ( lt lt t l nt r . t t t t : t . lt lit , ( "lllt r i) lllilir "l r r ,,t,l t' ,ttr l l tht lLt it t t 'r r t t t , , li; nt r t t l r lr r r 'l'iir 'ai il( . li( . il t r r olr I r l I ||r 't I r I ||{I ( ||t I I I lll|, 1' ,.rl i zi ,,i ol rrl ri r r I r , r . r , r , lr ii ( li ir lr I 1,,11,rr trl rttsri . l ' ) r lt llr : r r t llr , , lr r lv : t it t r lt t t r r nt t ll t / r t l", ll|'t t ' t I t I r ' ,
t r l r , : r t l r , rr ,r |l r to i t( |, l , , r l , r 'l | : r r 'r ' r : t r t r tl , :tti ,'tIi ,,,rrrl r , , 't t I o t t t , , Ir !I ( i l r r tl r r l ,rr.rrr,. ttr l ( .t|l r . ( r l i l : ) , l l ( . r r r 'l r .l ( 'l r '( ||||||tIIt IIIIII r ,'t,l tt;r l ,' Ir o IIIt ti r IIL tr '' r ':tr r ' Ir Itr tItti tttIr l l r tr r I I rr' t I t t t t rI t t I t t I t t t ( N l cl t( l o l \l l , l !'r |) ,r l r r r 'o tttl

tl c p e l cchea l t ffl -:r,. D c l rrtrl l ,, i'. rI r,! r'r.r . r r I I r r I r r r . I r Ir,.:i rl i rr i s .' i ^ l l i ,.' re s l x tc td re :l .,.,sc* l Ituri i i rr1,r,i rr;.rr.r,r t l: rrrr.rl . r i l) r ' r i, r 1) T i ). u r* rr.i s o p o ,tr: r' i rn a ,r' cr dri :1. sri i i rrrrr Irri A l ,rl r, r i. lr,.1! ;1 111( \ l; r r r , { ir i) . l1) l i t,s 1 rl ' r,1 .r| r,rr rrrrr* c l j l i tu r.i i n l ri nre(i ,l l tt:ol rrrri l ri rrrrrl l r, , || |',.r| , , r. r| .r. r I rI r. r l tr.r.,ri rr- .i ,.r,1 :,1 r. I ' 1 l ti .,;r. I| r l .al )Ll l c:i rrr.tt i r:r L| l rr, L"'i I rr'rr( r r ' , lr r . r ' r " ir l.r I' r* 1 ,' rr.r' rrl r' ;rl i i1 r 1 ,ru n (i h i uhrir)a.vi rl ' i r,(,rJ.rrrl .t r r " il) 1' r r i' :lr i ir' l (' i r ;r.r' i l i ' r' i rrri ,trrttrr,' ti i ,i l t..rrtl ti trgrrrrl ,rrl ',' Ii l r.r,l rrr. ' I', ,', i i i , ,'.' i , ', I )l 'l :rlr r r r r lr ic gr rr I r r r r.ro Il :ulItr rrr:ri Io s l , rl r,s r,r,i sr i rr l rrrl i rl r, r,ol i $,1t,,l i ;t. ' I , rI rt t I i t tr,rrri i , I r oI ir ; r r I il rrIIrIrr,rrr,,| | ,i | | iIII(.i i , i | ,Ir..
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, ,i Dintrnerviibciiornoturr, 0t,l rlri , ' ll , 1 ..,', ::., it r. .lf',,1i..ir',,]..1e?{)). ' '. :ir, t i:l ts , . lv l l l )(l l to (,i rs , tu ,rrta ,1 ,

r r'rrr';r'r,r irli irrr.r'rii. r)rrrariziir.ocuromotoriiqi ale trig,r,i,,i, rl\,r rl r, rrlrirr.iilr lr rLrrrrrjrrrn:itirll ir, vietii, 'erv'hii la iroLnavi caro ar fol.nr, r :,r'r'rIr.rIirrIrcI , sll rrrrrlillrr,i lrrir.n1. f )ff 1i1le1rtegja sirrvinebrusssj n,, , r,,t,t, tr':rzirirr.r:i'lr.yir._ orc, (.. i''lte orl cu ril.lerea trig"_,,"iii,,i-ii,., Iir..irlivtlt,sitr1, 1.r,,r,r."'tc,. fi,, tle accea;ip:lrte,-iir: ',,:rrl,:'li" de,par,k,', '

'i'ililli1,,":!:::,i!::,,i:,:,,{,i#[":,ii,,iil*fr,1i,\iJ,"?:rlif,fJJ,,,:flj;.'i;iililli ,,t,1,:,1 i'i :, i

'.;i ;;;,;,;:r :rir;m; iriliiixt,,liilii;ilril;iri::iiii:r,li,,l,,ij11liil,'i'rl]rr11 l:llr


t') b i nl.trl ttrtlt, nucltttl

f,',i,,1',ir*rili**p,;ti*;.t,;ifiixr*ilfiit1{{;ll* 'r*ii;iliiltifi;riiifii:;#xrrn!:,;"!i,:":i',iiru#*,
5 $;*g*iiffi ;gi,hT,ii,,i

t;;: :''ili:ii,,l;iilfixr;,,iiiil[*"jlti4!ij1l{i"i1l;rlJl:,|':l'';]-:'"r I :l;r'r,i;i;lillj; ';il;i;ji:[ji],iil,1j;.",:ii{i:[]:l,ffiiJ1,J*1-i,,i'{#;i;

,:-i[t'id**,f*iir***"1,*n*i*l**rui:?',","l[ :l, :i;il,,,il-;,ii


I 'orrlrr Ii lrr.orhrs 5i de tumori aie glantlei pineale.

;r,;;1iil;1;iif#l*li,r*""""**-;ii#!{;i;x$*l,4,fr*#r i;, ij,, gtt'1,,ru i: iI ;r ii, IiiI Iri I hr*li*rtl st.,.ffi ;.}l I I;,t, :Il';r:'':t, ii, lj-;.;,t *
*i,'illJ:?j**ffi:ii."i?:*"" "..,"."",i1{iitfli*s:;

; ir *t+ffi$-**+*ffi ; ii lllli i li*':i*$*?i*ruTlfl lll,ir;i;.lirl; jffi,".it';;:;;Xg j:lir,l",1",x'1"{lli*ii:i":"dl?:':il"J'"{"'rT;


otareamuscu. jlliril;'{i,',ri,iffi l;:l:t #j:ifiT!:i{{:{il1'.::.,rj'-,:f
t l r l"; t l )rrl ri l l, i 11ipr r r r r l- r t rr r,rro rrr

:uffi.r*?; *",+,,grf:if .ir,11;li,'lll{rii3i#i3{,,1fr{$Sl1"fu

i!4ffiiq1ll;giEil{iti iili*i* ;*lffi I rriiiil:i,l::l:l::':l?l'1,:"il'l,il,,ii,,il,il,,',il,itli,"l';,ll,,l*ii,iS;jUruifii.,*f n:ll


iiil*iff i*ili mrniil,-'lr'-*'i-ili tlrft;t*'iti,liifi
5tl

rlrorr sint : a) oftalmrplt,gic [rilrrl,elalti in glatkr (lifoli1,(r; lr) sorrrrroilo lcritri: c) ataxie; it) lis1,:i,grnus; e) delir in faza acul;li rii stalo arrrtrcsl r,oufabulatoriein fazele tardile. Pzrraliz:iile ocukimol,olilor sinl rrrrclrrirlr,, incomplete sau ctlmplete, cu prezenla la peste 50]i din cazuli r lrlozci |:rlpr'lrrale fi cu oxistenla rrneoti a t'ulburirilor pupilalo. Acrsl sinrlrorrr 1,s11' rrodus printr-un defic,it de tiamind, (etilism, tuibuliiri rnol,ulx rlilr'). B) Bintlromu,l I{estenbaum ( Bindronlul periapetlttataL ) rcr,lizoir,zii rrrr rontp\l, clinic constituit tlintr'-un sindrom Parinr"ud, la, c:ne sc rrsLrcirrzri, irisf:rqmusdisju:rctiv, mioclonii oculo-retractorii, tulburiiri pupilaro ryipnllzc rLuclea,re ale perechilor III ;i IY.In acest sintlrom este aiectal,ii srrlrslrur{rr, cem;ie pei iapcrluctala, nucleii oculomotori si barLtleletlL, longil,rrriirrrrlii, posterioarS,. Leziiutile cele mai fr"ecvente sint da natut'il infcclioasr'i s:r,rr ischernicii, (ocluzii rle arterelor plandui posterior al pediculului rotr.urnrlrniler, sari ale ilsusi pediculu.lui retromamilar (Aqgian ryi Vuil, I l)5$ ; Pop.r.icir, 1965 ; Popoviciu $i Afgian, 196E ; Aqgian li cola,l)., I l)71-i). Zona responsabili de aparilia sindromului I{estenbaum este replczcnl rrl,lr, de un sistern morfo'fu:rclional periapeductal mezercefalo-diencciir,lic, crrrtr rrrc conexiuni cu nucleii oculomotorului qi cu centrii oculogiri din tnrntlrirrl cerebral, prin comisura albii, posterioari qi prin bandcleta krngil,rrrlirrrlli, posterioarl (Bentler, 1965; Taube qi colab. 1965; Pasik, 1965 I Sh rzor,, 1965 - citaii cie Popoviciu qi A,;gian, 1968). Popoviciu $i ADgirn (l lxis) nu plopus - pontru fenomenul de ,,nistagmus retractorius" * torrrrrrrrrl de ,,mioclonie oculoretractorie", ari,tind ci aceasta are ca, substrnt rnollirlogic leziuni vasculare sau infectioase, reversibile sau irevcr.sibile, ils('til,o de multe oii de hipersomnii qi de mutisms akinetice (Popoviciu qi collb., 1980). C) Sindromrr,l Lgle (o vaiantd a sindromului Kestenbaum) Bo (litrrl(iteuzeazd, fie prin palalizie bilaterali, ile new oculomotor connnr (1n midriazS,,sonuolertri fi uneori paralizia miqcd,rilor riculare cle vcrticir,lil;rr ttr, qi mioz6,. I:eziunile rcsponsabilo dtr }rorl.rrrxr{ie prin spasm de convor'gentd, lea acestui sindrom sint de naturi, inflamatorie sau.prolifclai,ivi,. D) Leeiuni,le ttu,cleureala ocxr,lonxoton ,ui comun, tnai illos ookt rlo naturd sifilitici, duc, la teducerea tonusului in murschii oculnri, irr sprr,irr,l al ridicitorului pleoapei superioare qi, in conseciniai,, la a,parilia urroi pl,ozo lalpebrale bilaterale. fL unel) cazuri, diferenlicroa fu,lii rlo sinrlrornrrl Olaude Bernard-Ilorner este thficilS,. E) Sindlornwl arterei. nuclatr,lwi, oculornotorull,wicornu.n (ALlllolli 4i cola,b., 1952) implic5, afectarea n ucleului oculomotomlui oonrun, nn{,loii (,omisurii posterioare gi conexiunilc vestibulo-cortir:a,lo. Artoril rrrr0lorrlrti perechii a Il.I-a pare s5,tic o ramurti a artoroi sulorrsrrlui htonll, rrrxlrrrrl,iv tu a,nastomozii intro artcra cc,rebeloasi, supotionril, {i itrbolr! corrrlrrir,lrl, r io i n'ir, . sbe ix.r 'Ir) $iw)romnl Lwl Aaenlald, Sohuranberggi llu,m'pol,tli(nil;rr,trlo Alsorri ilirglu,r'u lirilr,totar[, oir,r'llc1;or.iznlii plin uxisl,rrtrf,u csio o n rir,tt 6i <xlllb., 1.1)67) rlo oirltrli, (ru o (lutitii;i'i, lrrrxlio tlo 90 Noo rr(Lr,lrt r:l,r'oir,ll,ur.tr rr:tzr), lllrillizirr, rr ;tolrxrhiirt,ll.l.l, cu ir,r:l,iv il;rl,ou, cornplol,it, axngorrr,l,rl, lr, rrrrrirorrln,t,ur.ii lrrcr.(fottrrtrrrttttl tlo rrcrr:r,sl,il v:tlrfl, lrti rronrrttr). Anllirl, ,,rriclic" :r,l ooulorrlll,or.u

t r ( 'l l r l i r l r r r l r r r o r j l r zi i , i tr r r r ,l r r r l ) r 'o ( l l l so r L o l r .zl l 'o tr ti I,t'ttr r |.ttl i Ir tt'r {,r \'r Jl r {r t l l l \ '( r 't l l i l l l '. r l l i tl i z{.:r zi 'i t J i n r . l n t t u l l l u n i tl ,r I,,r .l r r l ,tl l ( Vi cl o l q i r ,o l r r l t,, l l ) i l ) , '\ )r t n l t o l o g i r r . i t t r l t {r ti .i tt i r l r r zi l r ,,l r o l i o cttctr l .a l i td , l r cttl ,r i Itr tttu r t:r ti ''i r sr p ,ti t'lt'i" (:iintlrontul Gttllrl ll rtnitlit:). Sernuele eiLrtlitrirlc it,lc :rcrrsl,ui riitt-

It8

jn*ltt i lii tiiii*l'l; llr,,l iIril t*xxl iIr lli:in, ii; * ;t: ltw binc contr',tr'r rs,,-*"'ris*iiiii''re?4; \,oiculescu li",'1,,li,i.]'"ili?l;'i*t'rLitr
iJ,4.it. lhrolizia ncrvului paletie (trohlear) :!..1.;1./. N n(r de semic,Iogi,e oblicul ma,re, care Nrrr.vrrl lrrrl,ctic (trohlear) iaerveazd, mu;chiul t:Lrlrrtl ot,t lr,, produc ",,lro:r.tji

:liji;li,illrili;l-.ll$r iiilri ;rillrf ri, ll,ir;ii,,ri imi:lii;iiUiU_i, jitit

rrr' r'rrrJii rr*'rrrrrri. :r1r,,r'r,.rrii lll'l\i'lll"lli',illii;l;'i:11i;;:;j1i1'1,,1::.'::lllrllll.'tLfi"

tl t' l l l ttr r t'tr l ti i tt IIl r r l r ) l 'l r l 'r t l i z i i t l l t'l '\'l l l l l l l r r r i r 'l i l l r r r r l i i tl i i r l tl r N 'l l ( [( 'l ti ]l l l tl 'l l l l ( 1 1 ( tl tti i l r ti tt l tt'txl t'sl t r r sl r r r r l r ttl i i : L c t . o r t l i l t a r l 't l si ttt tl r ' l tttt'l l l t ( [( '( l l l sl l ti ( \i l to l 'r 'tl l ti i r t l V:l ci [l l zi l l ) i l r Ittttto tItIr '' r . l t t o efl l l i l i t't':;tttt i t i o , tuu"i po sl ,cl 'l o i r t:r :t l ttl r sl 'l ttt!'t'i o o n r l fi i l ) ( 'l 'i i l p ( r l l ttr l 'l tl c' l o zi tttl Il t itr portiunea

fJSf iff*"ur?#j": ll,;ll;l;,-;li':till,:';itx",{if;i#ii#?;31[.i"_fi ('lriilr


., r prrr':r,rizic d. gradmed.iu a muqchiurui obricmareestesuficienti

ol)rrsi.' I'^r'rr oblic rirrr<' tlo lrit't'lrtrt' i'tirl,' rrrrrrl.hiulrii ;;;"i";;;;td;";.1ii Hi vrr rr nu(l(l'l'ti1' leziuno lizia bilaterald, izolalit rr ttt't'vrtlttipatt:tic inctici fhgcodr|--ll"llwrI' 1pp13pi {i-ferenrirtd rL' .itrrItDtttttI [x'rt'itrlr.ii superioarri cerebeloasd ortcrd, de Sindromut b\ ^(s.itrdronlll(I()IIj'Li1'IIiI' *,,r]oi'in-" a tesmcBtului) este un sildrom inezclcefalic all'crrr' lt.llt. a#','t".tliii. o""*"nii n-iv-u .oot"*latcralr' bemisindromcctt'lt"los olrrltlil pil,r'trotl d" lrtn"Jf- *,i 1""iirin6rom senzitiv tle tip slringomk'Iic, Ciaude Eernerd-Ilornor i It i ItI 1r'I'It I leziunii. Se loate asocra ot *-d"o"l Leziultile lntereseMi' lxxlttntrttlttl *"*Oitni"' *u. hipoacuzie si chiar o "r,,oJ"io",-1"*"iscui prrpil r(' fibrelo metliat, lemniscul latoral, i;";;;;, ;i coliculii inferiori. sirldromtr'l :ttt'h c) Nucleul perechii a pa,tra mai poate fi implicat itt .

;;I :;Illj;il;ir, il,#[Ii$:1ff:i!i".'" i;iff

vertislrd a imaginilo" liliill,iil,,'1,,1,1,',',,1,':Ji'i'ill#3fi ,!g-P.u"1':' .*'"94di; inciina'li ;j;

*n ii il*iii

ile lcziuni tt":riipia"ctati sili,sizd'rimut tectl piotlus

opifiznnr'

2.&.4. Paralizia nervului oculomotor extorn 2-4.4.7.Bum'at d'ed'atesemiologiae


P erecheaaYl- ae$t eaf ect at 5, in30- 500/ u. t lint t lat t lt lt . l'zt lr ilt llllt t . l' llXll)' implicn paralizii ale mugchilor oculomotori (!hrad31- 5i Schlczingtrr''

r;;;q1,;1;riiiiiurriLi,rhn1ir,:{lir:lrr{,rf*ir#jirilnti
afecral 5. i n

ii""tii'i.", r" ttt. Aiest ultim finomensc explicS' I" !(tnlirrlrr li:.;f,:i#,1i:""..""'t'lTirui"?llTHHii#,f*.tiilii "l#Jii'r i#il"ei"a ;li .""unre""t" lr privir'u in jos ;i tit,div15t1n1;t l::t1:':l:r.:lll riiir'il; l'.11.]ll.:: csle convergr.nl,iar mi$c.'.or d(' iru(tllopclr. l{l.r'rrlrrr in Susl Srrabisn?al 1,, ll ; i' 11,,:,:i:1 i l;1,,,:1, 11),lillil::;l 1'll compcn'satll ;,r\{;1*?J,?*1.1ijli Capul esie lirnitat5." l lilil 1:' -l:ll.li1 rr ,..rr.rrl -este-rotal' t':rlrrjiziikrl r.rrrhi- in iartr s_auinstalilt ,i s""i" d"'iiipr*_ ""i""'r.ip."il" sau liporlt'opl'trltti "l", mod gr,,hat ;; echilibrii intre hipor;a'c{'iunr:u' .;;';;;iil";;i" para,iziei ,i;l;ll"i",,"lllil;ll"llll partoa -.rtopt..r"i cto ,,ll,,i];lii':i,,:l;lilr,ii';Trlli3i*;+i*i":i"i*i"" cxtorn
( t ( l lt lllgil r lr r r : r r ; l par ezel, ' dc per cchc VJ do gr ad lr r cr llll ll

il ;rliiri:l,tl;iir,;iiril:l.;lriu,*r,;'an'l*lxl*:i*#lii*#
,.,,,,,,rr ,r,, r.,,.,1,rrrrir, ,,,,,.,"o.,lXiulil""lt,ll, roilcr ;i 'u'.:n-

1tild-1#l :;ll;iili'l',1;,,11:;1i.,:l1;*gT{,i;;ff :i'TT,:'^'f

ad Popoviciuqi Pascu' 1980; Ilatsud:r,1'q63)' citiigi-

inrrgittt'.ttrt'iLrtl'rt'rJi Dinl'opia este bornolaterali 5i orizont'alii" Firlszr' jos, u.gor\r s. irl)r'i.)'r. colror.lrL. se incieb1iteazi,orizontal itr privirca in priJr

jllil,,,','l,,ii"ii]",liiilil,,,ili,/"lilnll"9""oas i"i't"i ' (rcrrers;n)i'i"-'i"a"ui""r ,rj"{X1",' si

t t t drt tl'iugnosl,icetiogtntoienic toltograf ic 6tt pa.al.iziile ,si , , ,.,,i i l,',",j,',,,,',',',,:'"lt t,.,. ,',,.:,r,,,i,iilt, t,rl)rcu,l.are. inso!,esc jle-cjieni pa.rali-aiilepercchii ,.., , ii

i"t".i' iiirrp"'ritri"n"" pctrlru


carurifd ""nirliouitut initi;lo dacfl teziunile

.lllli'l Jll -::iitt.l {tt' slirl}rlrl' prirnrl rlatil in :lccast'iililzi! osl'ttllr('u au ?ost tlrcpLc satt stingi'

:lp"*1'

,lll'li,!:r:l;i;i;ii;'trltTi.t#'iT*fflti,rli!i:,r-1J*?:{'l,1'r'4 ;fil"ill,,;lli;,,tt]:",:;#;;,:;y3ilii";;;i; jii:,i['t,Hf


iii,tii'l :i:;Kili;E:f:::i#,,Jffi,/,,:i1l :n,liil lL?"li iiili,r'li,,if:i:;i!i':,,,{:i:'i 1l !\tratiziih:
) nttderr,rr: rlp IVa sinl gr'(trt (l(r(li[('r!'rrtiitl; ,trr il(\ r1(lt(\ lr,rr.rlir,rrr ;,,|i:j;li:Ji:'.rr ^,,,, t
{! r 1 i ( ! l 'l l , u l l ( ', o l 'i l ti l a ,l 't'r l tl .

ti'tt1to'rnli;iilrt pt t'oTtogra[i'a e'ti'o'pntogen'itt 2.4.4.2. Problemade dinllnostic neruultti oculotflotor artern. A)Para|.iziilalron'tn,arc,sitttflelcventittl'ilrti|tl,r1ll1;rrril,i1|'rr;rltrlttirlit ttcrltltitttttl'tttt ou"n"fr6r-,r-iii-o'ai t, t,rrs"rrl o.l m,i lung dirrtr. 1,.fi norvii vttlttrr'irltil trut,i rxil,. nr{uri. 1)l rliforif. rt* !"pii*t rn f,,i.',i,t ;i;;;;";"r.i-j tnzonainca,rctrcotpur,,,,-*fitt""t'1'otnporl'ltlltriqiltil'trrrrrtlolttsittttxttl cavetnos. a)Pt'oaesauuS|lll'I'(t.(11t,'sittct'r'ulrtt:ttlttttlttl'ot"'rltttttn,portxlllott'tlVli"r'itii lirrttic :tIrrrlrirtli'rttt rtr ( sd lttittt:' Arlf..l' ittlol'tt' til, ( I ' I I r :l 'r ( !t) ( \' t "-,riuiuu,i, "ao. t , , r z i l 't r , - l , L t ( '{r ,'l tt'i l l 1 l i .r i r kr i ttl .t'vi ttt'ttl o ttttl L tl r i t.r L t'l tti , t I t ' i I | ' I ' llitr rItr|.'Itt'||'tI il itttrrttt,irtrt't'I' iiilrr,i'r,pl 4i rr,r,hr'ulrt,biritrt,itlil {ra,rul lrn1;r*o. ('iu'ot'l(l{! rrfl{tr.i tt lrl6rrlll' ir,lli"t s. l)(r li:n'ti. Itt s!tlltslll 'llv('rlr's tt lx)l llli(]l'll tlotvttl txtttlttltlttl'rtt' tttl,tt ',llt'l'(rll AiLtt'pro(t('x(ul ttl'ttudtrotlt itl,tirrtc, I li llr i,r' l5

;l,i;i';'iiih.lill;lill,i,',J;illiij;l',1,;ii;*;l ,,,,,(,,:,,i{,,,, , rr:,;,,,,,,,


l,'l';,iliiil,j;l:;iiillill;jl,

l-l l,lll'ililiifiilr;iritiJii,iiiii::rlliiilr;lil;l;l"ll';11,i:'il1'll1;t l;li;"i;11,,:ilil, r'rrrl'r't,''r( :rtr'r't'rt' Ni rtrtzir:tttt rt'' r1i.''"'.'".''''


gi l o,

pu"ro'J,ili,io,."u. r,ezi.nea ;ll,I ' ];l ; l";i';;;l'ii";:"r"..1;?; fll,t"-l" ^u"."';i

l:r r;:' lr ; ;r, li: ljr riln ir#rl*i:",ffi 1;i:{"g:#qJ#$t? i, :, ii' Illi1,ji ;i, I';I iii[,*31g rl,.;l1ii'1illl::t,,tr:,*!#itr#::*#"*{,ffi "k::rilr*11#x"ii;*t .;x?d,Ti:Tif"::,ff;:H:
Lr,,,,il,il iili it Ijii1,liiriili i'ili*i

,l.'',,';,il;lll'1,*f '.,il;1,i{x'ffi i1t"#:?",'"'":HtJf,[gilii*1',?l;,

ll;;ii: l;:lll;:ll''ll'i'l;,iliih"3 ,*t":1rgoame 'runo'"i

"l'":#i::tlfi ri;i;itr1*llr*rl*l"l'ai*ffi *"!*;l{6ryffi.,##i rli'll-li,:*l',::*;,:,lh$.t"i"rli,*xJi""';ii#.#o"",."*,.., '"'n"ii"i,


.i""ii"",fr"

;,,:1i:iliimk#;il**i5xrl?*atr,':ur#fff :: ;l;;,ll;;ir-l,,lll#Tif i,:,ilTiiT,?fiii"*k*t"li:x

jl.ii,l,i;l'lil'i,:ii:,'i?*ffi lr"*",:i:t":*;*lii;)*T""*,tT.ff "i,:":#;

i-isrr*,t*i*i+g***g'l'am':ln*}i;ffi

;i,,,i;-iir;:i*zui*$*"#ti+*i*$ffiiluts,i+rffi

stincii te,n. #:;';:::,:,i",!'i:w*.,t,f3,wi. l,:,.,!,:.).!:':"r::i,'!::':i;j!:,li:",,#H::^

1,'.,,;11:r,iilir;ii.,Uil{-$1$l=qitr#,*i':iI:}{1.+l $ trigenicu':L i'tii l'.:'n**" $"'JiT,'""!


i, i' liii :i I lil ;ririlii?*ii, ffi ,'[l jd'jff'I' i j jlt',lltiliil;l i'dtr{trf*lil,Hi ,t I

iil;r ilnriliix#"*n* iipl4*1n,htikirilH


r.Hrr* irrfr )vlrriru rrrr z.rirz.frr(\rr 4ig,,rr,ri, irrli,r,{ii rrxl'rrr,,;:ill,ll'l'lil'lJll,'r
[$

r.96 9). h) Paralizia percclriirr V I ir :r,llilrerle :r,scnrorcrr Si.irt sinilrttnu,l.,liutlti ^ pi 4n, celL sJewidale al ,uirl\tlui or:bttar. i).Tu.mori ale fosti 1tl,ru'ir1o-Ttalatine ptotTLa ltilroestezio qi rrcvlrlgirr . jn teritoriu-l ramu-r.ii 1r,.ll-1, l ncrvului trigcmcn, hiposecrc!,io lrr,r'irnali, si pa.ralizia ner.vului oculomoror e:lern. j) Paralizia cronici a neryului oculomotor exl,ern poate consl,itrri prinrul semn aI unei lu,mori din regiunea tli nl,rt drful stincii yi sirt.r.r,tlrt L carernt (Sakalas qi colab., 19?5). . B ) Paralizi,ile rad,iculare (intranearaniale ectranucleare) a1tlr. (rrl mai fi'ecr-ent ale porliunii ventrale a protuberan{,oi. -in,,lezitni ,\ ind;rotnul ]Iitlard-Gublei esie lrodus iie leziuni ischemicc itr l,tl.il,o riul arterclor medianeale alterei bazilare. Clinic se traduce prin tnrrirlizirr facia,li si de ncrt, oculomotor extern ipsilateral, cu herniplcgic tli. 1rrr,r.L,'rr, opusl'i_. Forma clasici a acestni sindrom are u:rele variantc, h funclic rto extinderea leziunii: a) dac5, leziunea se intinde posterolatcrrr,l ryi iirfi,rrr. seazi nucleul sru riid:icina principali, a trigemcnului, la tabloul cljrrio amiirtil se-adaugi fcnomene senzitive de tip ilgic sau parestczic pc Lcrrri, fala homohtelali ; b) dacri leziunea se intinde nurnai in diroclic 1xrsh, rioa,r:i si afecteazd,pa[glica 1ui Reil, realizeazraqi un sindroru sctrziliv alte-rn; c) dacl, leziuncase intinde in direcfie medi.rnir. qi cupr.ildr: trolvrrl oculornotor ertern de partea opusi,, apmc o parelizie si a acr.stlri nrtv ; cl) rnar::i leziunea se intinde in diledlia crlotci plotubeiantirL,, alirol,rrrz:i qi n:untleleta longiturlinald, posteriod,ri,. Q ) Pu,raliziile nuclearesint in gener,alrare ;i aprl rnri eltu irrprr,rrrril, cu al.ctarea altor sttuoturi neryoase din \-ecinr: i,iit r.. .\stlr.l. Dlirillizirr nuclenri, de ocu-lomotor exterrt apare aproape tot(lc:runa lsocilrti t'rr 1,rr ralizie facialiL periferici.. Nucleul perechii a lrl-a sc :rfLi aproape elc rr:rrtrul porrtin l,onl,frt plivir..l ipsilateralir, de la care o cale tlc asociatiecorxlticc,prirr intrrr.nrrrrl irrl bantlt'letei lotgitudinale postelioare, la nuclirul pcltlu nrn;clrirrl rlr.rpl, oxtern de partea opusti,. Acst ccntru ponti estc Nd{rserllfccttt (lc lcziunee care inteleseazi, nucleul oculomotorului cxtcln, qa incit, po lirrgr"l paratizia de nuqchi rircpt cxtelrr, :ll):ll.e;i o paralizic rr prilir.ii lir,1,i,r'rr,lo rlo ilc|p11r.i prrt' qi tlerilfia coniugatir I globilor ocrrlitri rlc prrrtcrl,oprrsi. O rfr.clltne limitet.i h norvul facial si alxtucerlsilc rrcrct;i lrarltr {i fiiri, pararLlizja miqci,ritorconjueatc r1r,latcrialil:rt,r, sugcr,c;rzi o loziirrrulcni,r.;rll, la m:rllinca infcrioat.ri ;r ltrrniii, lndo lctsiti rloi no'l-i lliliisr:sl lr,rrrrclrirrl certl,r,rl foarle :lplr,4c lrtrul do r:itlirlrl1,.t)llnllizirr,rirrtleu,rii irilrrl,rrlrrli de ootlornotol ertenr nu txtc rlr.ii, rlacr'ii:irrcurslrrrrlr rlo lattl rrl ri, cli rkri ('oncornilr.trl; trucleise giscsc in apr',11itrr'. s(rlLsoci:lzii llrrlalizilrrrriscir.ilor rle la-crilltate ;i plr';rlizi r rrrrilrrtcllliisirrrlriluict'rrli Irrri:r,lii puiliilicri. at Sinrlromttl lui (lus?tiui (sittrlln,ntl ilot;;o-[t lu.or:a urLulftl lrqnt: . tttlui pontin) s(' lrlllit(i1(nizl'llzi (t.llIti(ji V, rlt.fioil lrl tt('l\.il()r 1rIirri,t.rrIr TI,YII qiYItrIrl, lrurl,r':r llzirrrrii,lrrl)rrrlrilir|^ scrrsilriliiirlr'l,r'r.rnoll!:.r'zill, (1('\'iil1 de pi,rfor,ol)r tsii, il illolrilol oirrrlltlisl)l\. 1)itt1r!ll sililolrsli rii lirlrrgrnus {ilrc bfi1c tlr 1|rr,lr':r lr,zitrrrii(l{r,rrlr.rrlriilrl lllir?: ,l,rrrrr 1i \-lrsrrlgil, r|()rrisi .Nlonl,rrrtN,l'i, l!r(i0). lt\ Sintl.tonrt,l. Lu.[ ll,utturtntl (*irrltrnu.l urrrrltl tl lt,ilnht't'(nl(i ) \rl tliU'irrllt'fizu ,zii 1rt.itt lt \'1.:r rlr' 1Ir1l1,1q lr.zirrrrri si Drrrr llrr,rrlizirr 1l(\n,('lrii
l l t r r t rr I i t t o z i l , d ( ' l ) i ttl l i r o l r r H i i .

.a,t' i tl uroidit r ( lt ot r nr , l, llt t ) i'i l) l

lr , usir r ollr , b. ,t lXi0; lii) g( , r qi colr r , lr . ,

rt

(ollllrtropklliik' ittlortttttlt'nro) :1,4.!i. lhrnllziilrr ittlctrrur'k'rtrr' rlill I(rza,r'oll I )i I tII II' II' I t' i lotrgiltttli t'r'zttll,ii, o,ltnl.n11l t11i il.r 'iul(t't'ttt:l(xt.t't ( lltt'lr'1t't'olr, siltt rrrrlr.jroilIcliirrrlr'. t'st'trfirt)r' itlo palaliziik-rt'ittlt'lltttrrlt'itltr ( sr t.lrs('l rw(,grfr', ll)(i9) : a) rrt soltiul drept illtern este para,liz.Il,]rcntr'l] (,rlrr.iugalri, tle lRtclr'titatr:, insi, funclioneaz5,norrnal in timpul |||rr1r'iri(.r| prepolgcr,,rrir llglrr{r'i ; ll) prozerrla nistagmusului tlisociai, singular sau_ glo}lilor paralolismului prezerlta privefte orrlriul in afarri; c) l.rrl lrr, oiro ,r'rrlrrli lrr plivilca, inainte, in ciuda parezei bilatelale a muqohiului drept
r ll l (.l l r.

t
il 1
I
ll

pozlina (indeosebi vasculare) se poi intilni doui forrle 1.,'.:irrn,ile i ilrrlrrlrr rIo oltalmoplegii jnternucleare: 1rrrr | ) (),lltlnto1tlegiu i.nternttalrard,anlet'ioa'rd, cea tnai frt'r,r'cntil, aparl+ ,,;r ,r ,,orsr.r,itrtii a leziii'ii fiblelc)l care leagii nuclcul pcrcchii t ffl-a, cu rle partea oi:us[ (r'rlr'Il Donl,itI petttru mi;ca.r'eaoonjugat5' orizontal:"1 (lrlrlr,ll rrscrtrtlrlrtr:ale bandeletei longitudinale lostf ioare). Clittic sir |', |||rrIr';i,lrr plivil'ca lateraid, paralizia muqchiului drept irtteln (de p,rt'tca tliptopieincruciEatb, r rrrlr.sr.rrllilrrzittnca,), $i lrjstaguus ulizontal la othiul r':rr',.pr'irlsic irr lrfrrii. AJoste lenomone se explicr'i?r'iir 1ri'tnl ci, nrtcleul ;rr,rrllrr rrrrryrlriuldropt intern nu primeqte impulsrrl'i pentrt mileatea' r.orrirri:,rrIi1, rle ln centrul pontin de partca ol)trs:i.Pe de altii pnrte, lrrl,rtrrJi, rrrrr,lorl rrrrlvrrlrti rlbdncens primeqte impdsuri cerebrale qi vestibuJare r; rrri IrrI r,r'rrIrr fi r sl,lit funcl,ioneazi normal. Convergenia se produce, intrucit rlr. l)r.r1r'u rc('rstir, mifiare nu trc ?rin centrul pontin aI mi;clrii la1'erale r:rr ,'{,| | i ||ri rrI r' . I)rrrri leziurrea este bi1il,terald, apal'e o paralizie a adducl,iei l,lolrrrlui rrrrlar irt arnbelc sensu'i (dar cu conservarea convergen{ei)l | | iIi I i r:fi | |rrIr.rIrr liot'alo din ochii afla{,i in abduc.tie li nistagmus lt} privircir. rrr rr|11.\iN1irglnusul opi,olri etic qi indus prin excitalrie vestibultril cvi rlr'rrlr: zir list)rrsrli tliferite la cei rloi ocli (Bender,1969' cita,t de Popol{).B0). r rcrrrsi l'rrsr,tt, este adesea greu tle _diag_li ) | ).llrtltrtrryilrlti( internucle d, Ttoslerioard' r,rtrri. i) 1rrr,r':rlizie supranuclearl a, perechii a Vf-a este foarte dificil rll rlil!.r'r'rr(,ilr,t, lil{ii, tlo o afingerela nivelul nuclear sau radicula,ra' net'r-ului \ t (llrllrlri si rtlab.. f9;$). I{u$chiul drept intern de partea nelezai':isc r'.rrr1rrrrIii rrolrrlL),iri schimb ml;chiul dfopt exterl de partea ]cziunii rni In aceastl' formi'l sint lrrr! iionllilzi'i irr r.tu'srilInisci ilor dc late,ralil,ate. l,'zrrlr'lilrlr,lc rk,srrr,trrlentc ale bandeletelorlongituclinalcposterioale {ile ltr de aceea';i {.r'rirrl porl'ilr rr1rnilciit'ilor dc }ateralitate la nucleul tr'bducens (l)rvllg(,r11ll, aprlre de rrormal, NistagmusLrl orizontal srr lrirr'lr'). llrotlrroc olrrtsi,lcziurrii l:t ooliittl c:Lre?rjveqte in aflrii ;rirr'lr,rr intlc celr tlouli forrne se facc pf ii'l lruliza' compr,tr'tlrii l)ili,f('r1,ii^r'(,rr ( irlr, itr:ti{)llrlrzii, in seng orizorLtal.Astl.el, in forma antu ioiir;lt rrrrrrrr'IriIor' rrl r,r lc|rr il(f l)lutea leziunii funcliolleazi normirl, in tirup oe clrcptul rlr r,1rl rrlr'r'|| rlr' |rrr'l0rl oltttsli cste I)al'alizat pentru miqcareaconjugatil,de l:r,telrlilrrlr. s1rlr. l)lltetu lcziunii, insL fulc{,ioneazi, norirral in convergeltit' iai'ii, rtmhii drtpli jntcrni :ru o arti'r-itate normalil, a1,it Irr lirrrrrr pos l t,r'ir N rnai r:it i11timpul corn-ergen1,oi. rkr l.rLclt.tlit,:tte, rrr lirrrlrrrl rrrir;r'r'ilii "ri pcrttlr'u. mi;carea tl'lrtterlr'r,l)lrl('\l{,1'rr rLr prtr' 1t,ir loziunii cstc pat'alizal tltl ltalirlizil,ptr4llitt zisi Ii tli'lirt'ctt('ia,iir, r':rlilirir'. lfrrlrrlr lrorict'ioilt'ii 1xrrr1,o
(krllrrtrl 1i I t 1 r| tt' t' lt ii rt \ lir ttttttlit i lt r ilt lt ' llr ' lI t lt l s f it t t t t lt t t ' t 'l l t 'i ) i l 'i l l f i f i t . (lllillt rrrt rrtrL llrl , : t , lt r r lt lr t t t l, ' t t t r it t r r lr t gir ' , r ' s l r ' l l l i r i l o g i r , s f i t 'r '1 i r t I l r l '' o l r rlr,

'in

(1i trtt lxrslctiort'ti) dc ,,o1lrrInto1tl,6ir' rllllrtlrllrll'ii tL' :rlxlrlr'('il"' 1r't'trr.ttii (1i lttt ltttllrirlltl'il)' , r i tltl rltltl.utrlitl" t t t t t ' : t t r tlr llt,irllrtoll ltrgic i t 1 r t ' r I ' 1i ,,o (1:l'llzil tttrti lt'trtrvtrtll'ri ti(rll' pliici eslr' lt) l)iaqnostic etiologio: 'rr'/rto;-rl 'in r, ttlti- sau bilater:lltr; lr) lczitttriltrvirs(rllilt(t l of lalmoplegiilor inicrttttclt,iu se iau irLconsiderarein tjotttoxtul clinic (Ifa ingtorr si cttlab., l1)61i;\!rllHll ;i lloyt, 1969; Cogan, 19?0; tr'dtzsch, 19?1; Gonyoa' 11f74) CJ Oltalmoplegiile internucleare pot si apari' de ambth piirli,.trsr.t rtlrr ciirtrlu-seqi o oaiecare asinergiea globilor oculari, precum ,1ipitt'rr'lizii prir.irii veiticaie, 1l sus, ale globilor ocdari (prin extcnsia lozittttiltrl lrott. -- r'iirt,l'i iinc in paltct'| inferioarS, a rnezencefalului (Cogan gi colab., 11)5() r L'. iiotlecht el, lC6j). 2,/r.6. Paraliziile oculogire suprarruclearc . L'ezi.ltlile suptanuclt'ilt t rrrtttt 2.4.6.1, Sumat d,e iJ'ata semioloylice afecteazij, mecanismele miqclrilor conjugate se traaluc sentiologic ltt itt : a ) Dim,imtarea *atr abolirea mi;cdrilor conju'gate oolunl,arc s(r (lirril'(t' ierizcazi, prin paralizii de tatera,litate, de ve*icalitate sau dc collv('l'gll lI r'i'. ln funcfid de iopografia leziunii, bolnavul nu poate sI'-;i dirijcze gkrbii oclllari ia comandi intr-o anumit[ clil'eclie. De asemenea, drurii rt[rrtt('itt' pacientilor este atraBrispre un obiect cale nu se afld, in fata krt',.lti.trtt 1i pot deplasaochii pentru a-l privi. Eristl $i o cresterell ,,tonicii;i'l'ii" ttlttrl chilor antagoniqti, care duc Ia o devialie a globilor ocul&ri de l)rrl(rir, ol)rr$ . \r apal fenomenc rliplopice refletelor de .fitalic st' pttxltttrrr ;ttitt Dlec&nismelor b ) Itttensifi,aareo, *,r itllil sLtlrcolr pielclereaconti'olului inhibitor. ln mod normal, iirlrtt tltpii, rLrlitr(ri. trolul r-oinfei qi ochii pot fi miqcali de la un obiect ia a[1,uI poate or,ltii tlr' tr2rnslix\r p.r''rliziile lu sri-li bolnavul !n supranu-cl"are, pe un obiect pe altul Ia comand5, insd poate uuniti i [u obiotrl; orttrr so se pot e!'iden tjtl uicllrsji Lrilllrrfr' rni;ci. in direcl.iaparaliziei. De asemenea, rolrnalo la stirnLrlarea labirinticii. Pie}derea rnisciil'ilor vollllll,iIrrr irl(' globilcr ocula,ri, cu lespectarea trtulor mi;cirilor ooulal'o r{rflo\(', $(\ Paratiziilc m\ciLrilor dc ltttttrlitrtlt', rrtr riurnegte pseudo-oftalnnplegie. pistr:.rer -conrergiltei, indicii o leziune corticdld'sar pe c(idl. tnrl,ittol'tt 11ult, inainte ca acestea si, a,tingi centrii subcorticali. In untlc cazttti, ilt rrrt'tr' contloltl voluntar se pirde, reflexele de fixalic pot dovdii t tt' i tI It i I tIrI I' , prir-irea se,,ancoreazi" de un obiect, lncit o mi;cart ultcriorl'rilIlll lxrirlr' lrt rrt,tt li fir.urtri decit tiupi, ce se elimili irnpulsrltile lctirticno (itrcltitlt,t acoperirea ochilor). :Lceste situa'!ii ar1 fost dcnul]Iil;r' ,,a'l!1t,1:it o()ttl'!ri tttolorie'1(Goldstein li Cogan' 1965). rlrr Irt. lrrlrititrl' t ) Intensi.ficutearcll(.relor proprioaeptiu cillo l)or'11{ls(' tlcilsul)lilllll(lf ilt)r gitului epa'e atunoi cincl leziunt'lrsc:rllr-t' si de la rnurschii pontini ai sistemului l'estibulal. Astfel, tle piklir la lttr clz lilcrtt'trttrilt'ritill voluntrro itL sus sau spre dreapta sint irrrfosiJ]il{',lLrltriiinsi ('rt,l)lll('sl,r' sttlr tttt tttt$lti rr{ttl br s'r (oborit sau illtori sl)rt! sl,inga, otrlrii str r.ott'it.zri sii srrt t' i rtI'rI It t'tIii, ltt lrozililr in srrsi1islr'(f {lrolrpt,it, ct':t1xli ilt Illo(l aul,ornfl1 ttt|tliltlthr<'il,rrr t't'll0xt'ltr ilt Ttityttt;i'". fii. Ilsl,t'.lcnonenttl Irrt'rrt'izotll; ,,oohilot lrt'tts<rii, icr', dlr,cil,llliri{ilrlil' crr,pllltli r^s14' LrrLrilirtl ;i rlt, crli;t't'i t trp ttl st tt i lr'
l r l o p l i o g r r p {, ivr , tl c t l l ; , r r r r u i k 'ttti i ,. l tt, tti l cl ttl IIl IIfj ( IIi I( || .'tl l ttl ti j ' r l l r r ,r i , ttti ;t:l ttt'i t, t'i tl r ttl ttt

lr

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t t'rtnt4 lttt

l)t

lt t ilt ) t . . x I lt , t lit /

rl.rrrrrrrr'r':rzi , r.zirrrr. r'rr':rrr'r'li.rrrolr,,iitl"",';,r" r',,iil],,,,,,,",u 'riscririlo' ll,ii,.;.iiir...i,rili"li :i':li'i,';,',;:ill;);;:;i,l',;;l:]'ili.-:1il,i;:;,,r.ziunei,


,,,. r rr

,, ,,,:;,1,,,,1'lll"-i1:';1"','i,"'j1i:.'i,ii,'iiill;lli,il,l,l,i;-;,,l,,i," llil,li,;i,i,,,1,,:iii,;,,'l,iil;
l' l)| (.1, |lrt0 se tnis c t j, di;

ir r r J r li|l. r:

",,ri,""" sint pii'r"1.te ,,,,1,,,,,,,,i,. ,i,,.;i.,,,;i,;;,;''il;';ili"Ji T,;:i:i:". ;|?1iil11:# tt ) t,tix:iir.itc


da .u,tmd,rire sint l,estatesofi"itilJ laci"ntuhi si1 jireze

( It )I |(I()l | | i I (' | | I sc lt t r t t lt t lr r r r r l. t r r l L, lr lr ilr l ( 'r ll. lllglllii ; l glr r lt ilr lt r x, t t lr r t t i n (l i rcl l i l l ol i r t sii llt r r lizir . r ; r rr r r lr L. l )ccrl sl r1ja libr elol or , r r louilr ' pr , t r it t t t ni; cr iit 'ilr ,( ( nl, jr lgr r l( 'I lt , i'r 'r ': t llil: r Iri l el !eduncular inf er ior ' f i lxlr r l, ilr st t pur ir t t) alr : t t n t ol i; t qt ol't 'alt l;it r : lr r bilirc:r, diagnosticului topogralic al It-'zitrnilor'.Astlcl, iIrtrclnpcrc:l Iilrl''1,,r' deasupra incruciqirii induce pitlalizia milcilii latcralo slfc ?l11crl' (il)rrfi,.

rita, la aproxirnativ 60 t,rl irr r,,r,, ,,,.r,ir,,,l.irl,,i;,;.,ilil|":;:ll:i^tu:!"i"

) 'l'rxttt!.ntet:u.n,is.mului,d.e l.ixuJie: piLcierhul csio sol;i,;tat pri\ i.:, r'rrrlr'('l)1i rJlfat. cramirxtoruiui, ilmp in care .roA.airu;o,rrL uir",;. ,ii'iul ,,l,rr'.t;r l,(,rili,r'i', .imltului vizual (#i;r:arit:a ,"ii"ii, _"ii),'i_,s* dc lLi,l*il)i). tr rr,,rt rrl.trurl, st: ltroduceo rniscare privilii iplr stinlnlui r,e:jljr,!.Li\,. r 11 r'rr.r!'' rr.r'srr:irnisciiri s.gereazii -a o t,,ri*" t"ri"""ur,i cr-iiLr. ;rrir_ r( rrr'|r (''!*1r' rrc re'einrui occipital oi ","u'li i,riir" i rre rir,,:*:. '|", t \t,4t, , tt( t ttttt'p) "i""riit gen,rri.., examinatolul cr'le borr[r\'rLrui si_i rlr,rnr, .. . " .,' ('.rr. (e

,r;ri ir,,.,, 1,,i"i,,,-ioai.i'T1il::"ffi.'i:-Jii:tfiil?"1i?llff:lif;,yui*or'i ,

ii, I

',,

,'i,;.;'rrr,

rni..:j5. lerNir fatraochitorip,:" .,io,i,,;",,ia"iiiiii

) 'l'r-'xlurau ( tl"stctgnustrltti farei l.ente ttptoltittetic. ,t Utl ect:ul tiriutcat |' ,, t)t'/t \l'rticaie de curo.i dileritc este in Ilta pacrelt,rrlr, i.r. .str r'i" soricil,atsii tiui,p'ir-irea u't 'riicat pe ceni,.lr er,-r11'r{rr ,, rlrri, ii'rt) irr salp ngeslj, esti miscat-l;^il#;,i;;jtr.u "ruJ'"u"..t,,ir'i direci,ii.ln ,.,rrriitr l{)t.lrlll(j apari: nistagmu-"ul -- ' optokinetic. ) ,. , ,, , ,., , ttirttt0tnusul.ui,_;c11t!Uuia,r rotator srLr\ tlistq(nt| ).tllu .rt ',, ,( _ i t ..,.! tttt , t t t . : l. t ., .t, (lir1 i r n l r ot,la l]t ^

nucleilur nervilor, .oculoin"t""i- aral \, .1rl)rlr1 ( sI{l ilrlrft. ln_prezenfaparaUril". iril21i"r"lJali'prs,irii llri,r:rale , Ir r,r ,r| | iI I( . r| jl:rrt,rr ulechii protluce ' numai rniqciili tenie. afe ochiuhii. :'. t.( i.:.1. l, uihl tu e rIe di a ElttostictoltograJia .,si etir.tpat ogenic

i"iilI lltllli,li ;li,lLl];,Il;?:ii:;lJ,Jl;L';';,1'f,1i,'"_,ii;1;tl":l,";:lfll: rrrr,rrrr.rl'rl, (J(,llsltllrl 'r._,i..,.'.,i

; ,"nu"u,-#iiii:,:?".,?,::t;,",i,",,x"::,r11:ij:;;;illi; , sirrt, -rii.,,iia-',1;;;;;," \,,,lrr,rtr' leziu,rcltr.t J)ri_..1rate, arc,tui r.eUr"i" ur_nuclcut ' l1iI rl,tihrrtlr (ncrvulr,,estilul _,.r t,,fr,l,ni iui Deitet,s

r) r, irrr,,.lr,rraliziti

,,,,, ,., !,:,'i;,,i ,,1 ,,,',;::'i',:i;li,{:i:,:,:,,;"x!;i:1,i.:,1:,^1i,,r"'1;,*;T:l:.fiH:T,,;"_,:


. l ' r.rlr' t ' lt, rlrrr lt <,r^ trlt.iloi O Lt t t lo l t ' rrrjli' r' r )lilriilo:lsii.lrr illr ir llr , , lr r r r , : r l. iz , iilr , pr , J lilii llrrrrhtst. f[(] lozil,lri in I l l l l i llul lllr,lrr,trl r,itrl r ir . r llr : r lli I t t lt i lt lt t lli' t L' r ' it r i 'l r l p r o t l t l s L r r l q l, ziLtlj r , rrN r(' rr(. r.. | ) I ',tt'lli.:iil( n tis : r r r ilt t . |, , , t |it |||, |t | , , t i. , , t t lr r lr . ( r i 4 t l ) , , ) 4 . 1 t 1 t t , l i . t , ; l l t , ) I , :r l I r I j z rr I r, rrri,r,Irr,r I r . r r l ir . lt r lr . t , t r lillr lr . , . , , r r , l, r r r i r r i I rI rr |:i i | | i I i I : I I r, .L I r r i r , , ( ' , t.r, l r,ol.il.,rtr rrll l,lolr r lr r l olr r lr l, r , lr l r , 1r r , , r l t , , : r ; , 1 :J rl fi,, . i,r,, i,,,,i,i ll t )

;iI; : r1 l, i, lli:liilu ;1, i#]r liix nsft ,,;li [mlri#"1*,uffi I i r;, 1 i


r , r rrl ,rrl i riI r , or r t ir lir ljr r a; rtb tl c t,

.,,,,ir,ri ;ilii d;illli"ftlrliii'iTlift:J.,,*"TT;l'Ii ',,rrr,r'.1,;; ii"i,.li,?i];

c.iilar aculolttc: I:i{/. 1 1 . L t . i u l ri i e : Ne!rc! .l : N.Eon mezo.cialnr hcDicrrltrrnrr ; .artnrl :rdliocnl:rrat.r; -B l i . ri re rn i a . c l l o n ' C : \ . r{ o n n e T. . e l a l n i x l . . ! l o n r. l . r, ] ri i . o n r: n ; 7 -' I ' . h l i z i c l.rt ll:i .\tdn : I - Pi.rli2ie n!(l.arr .onjlgali | ., - I-rerialic conjrrgai' lrnr leTirx' _crnisJ'r(' itTnD' tunjlgat: Dc;irlie )pNte'di.il 4 lrin

i n 1,i rrr1r cc i ri l lclu1t elca' 1ot sr b t lccusalie cat r zet zlj,plr llizir i lr t it t il ii lr r llt . r l' ci 1rr, rtct,ou5 ilt lr t '1r '. ' llot s] r 't t r rtlt t t t r ''t Itr fttttcl ir r t lt , lr t tt t lizlt lt 'it lt , zit r t r ii 1i r lr r pt it t t kr t 't , r tlt t l. t 'sir t r ! t 'olt t t t tI ' r or illt ' ( lil. i l: i . i lilt t t r i lr t i vt' r, iI r r 'i1lt I r st r : 't lt 'r t '; 'it l vrri rsr.rl rr l l g. I l ).

:r). , { ir r r l. r , r r it r llt ' t' ti l l t rttl r' t,i rt (tn ti l l Iri r $ i ? l .I t,nl at.)r,rrl r, . l rr..rl rtnrl 0 I' rrri l ' . r ' : iilul olr r lo ;i l r' rL .i rs u l rr,i r,l rrn l c j s j l l i i (tnl i l L,x l tr rri vr,l i rr,psul rr,r). l i ,, rrr:r r r ili. r lii 1r r ir r l ,r' -o rl c l l rl c l l l i l a te a ])fi vi ri i , rj l l ([{ fvi oi (]r\gl ol rrrri r,l i z i r, l ,rl ,'r ,, r ' ul: r . r ' i, r r r r r or.iq i i i r l l l )l l u i , s l )r' (,tr)a rte a l ezi uni i (bol l raytrl i ;i pri vi tqte Ii 'zrrr.:r ) , l: L r . : u' r . s (.rrs o c i l l z i -r, () p a t,? l l i z i o fa c i a i 5 tl e ti p central ,i o hemi _ lrlcgir'.rtc l)itll,(fr ollnsir lczinnii. L,eziulile cauzale sint hemoragiile, infalrct r.l r. i .i lr r r r ur r ilr c m i s fc ri e e . Nlrrriii'stiir.ilo inverse, ilitative, pleced aleviatii conjrgate alo globilor . ,,, rrlrli (rrrruor,i si alc capului) sprc lartea oprrsil (confotm legii lui pr6vost
I

( lr Nltttt ( lillt llt ) llllll 'supct 'i( n't ll- lt 'glt t l't r lt t lt t i lt ot t S xl .rotttu l f l( r gr t t nt t llrovillo ttrijlocill' lrt't rtlr' sorrtirrlirgir',tttt sirLrj'rotn in conljexl,ul t,in) culrirrdtr, gl'5rrli

;;;ililii';tti l,;'i;;;;;it leziunii. parlea olusl de -'

c,'i,'l,t,il's'ipsilatoral f i hotrliliipo.sl'r'zi'

It\ '{inrln,nul Fot,ille m ijlocitt, (protuberanlial superi,or ) cste realizat (1, 1,,,:rl, ir iilrlelor ocnlogire dup5, incruciDare$i astfel globii oculari sint

'll

tl( ll )llZ\').

bilalerale,iirs:i i'og^ltr' irtt p"tl"e sint aclesea ii'iiiiiii"X#"i, oil"iiriir" -irnpulsruili' rostibulale silt pierilute' risnunsulile ' *"-.'i"o*firiifn li pot irnbrlca, lirirrt

'",'is;,,air,rr1 fstiTll In.fPrioi (ptolltl)rtta!ial itll.'.itttl crlr gr'ttlt;rl ii st malrilc'\lI ptitr p;rlirlr/r:' O" l"riooi ,i".ailol oculogiri-ub inciucjsarp nl)11' a globilur o(:rllirri coniugatir alevjereririi:i.iiirrt" pn,1oaleziunii, cu siI(lr','t'l jnfeliol ,.rr urr s. loir,. rsocia.$i i'r,1"^i'-ii,gi SioO,omufTorlillc tl' siluirii sislemelo' tle asoci{rlio:rlr'.irlr. ijnj"tI ilin'"nua fif;iijt.r-"d i"cdmpt"te ale privirii de latiralitateorizorlh, c"."i i-pn" cintl globii oculrri silrt itttlrtrlrlrrii nistrE "tii,r,ii paraliziei. ln diieclia I'itt I'iraliaiile migcdrilor conjugo'te tle tertic:ttlilate (sintlttittrttl !) jll'rlischtrwil s' h "u'?Jrlunlt" comisulii albe posterioare, alc nucllilor lui din reglllll{'aLllrtr'lrrrrr.i .i Crial si ale iubstrn(ei cenuEiipcriapedu('lirl( I rrl.' i bupranucloa'r'rlitt rttrr aoietlo"i p.ino tibrele ocirlomor'o'i ;;"r;l';t.;;;i (ar\':r' si'-' L;ltiur!i vcrlicalp' ryivirii " iiir:'riiliilTj.'i;l o pu'i-li,i" r'r'l('(:tx rr'l inri-aor"rio' (craniait prorl'ucparalizia pr-ivilii i.n-'us, iar mai posterioare (cautlal) realizeazi parallzla prwrr]r rn Jos' rt' fn cazul in care pa'ralizia migcirilol, conirgate de vertiur'lilrt'1't' irr lta'ttthrl.lrt gdseqte se purlotizia miqcAritor orizontale, teziuiica din regiuner 1ep12li 1J.5olli qi Srrlli' llrtil "*o"irn'* r"i'"ii'iur"i5cle veit icalitate nrr apar in leziunilc 'irt;:ttl:tt' paializiil,' ""tio"io"ii Si;"i,bl;;i;i .i in leziunile care a'fecteazi' zotlil l)r{'l"r ntmai ci sup'eriori, r-" tooz; Pasikqi colab 1966;Bnderl1)(i1r) i.rx"oli*fifo" . colabl, ibt}t;.rttltli ' oxtrltrlrrrtt Sindromul Parinaud se mani{e)t; prin imposibilitalcl portlr'lr ocuJari' globilot' a -hlr dr. coborir(' rolr"Ariiol de titlicare;i1 sau paralizio itttrttttilrigcare de verticali{ate' lntr-o ,n"iiiA-.ti."' i"ii rr'.|rit rtpui in sit''' priririi "";,Jf.ia" t"ri it:"cl,"nr,afcctarca i,i"ti. i'iiiriitat l'ir'trk'trir jos foartc "el apare in numai to ti.p ce i; ilb;];; ;;;! ;i lrr l1r ilr_?irir,", il--ll.s L asociizi rdesea cu absenla rcaclici l)ulilxl.(i (lollv('l'g('rr1rr dtr ' ;i; miclriazS, relativ2i li tu menlinelea ree-c{ici ;;t-. It''" tlisprtt'i{'irl jos, plus ln rparc in privire Daci,'*;';ierd; si iniqcareade modirii qi a oonvergenlei. aplorpr. do uumJrlo\lllllll(l{'irf rl ReEiuncr precolic(llal'lnsle fl':.rl'lc I rr ..indlomul Pat inaur[ {{' 'rt(rt'iirzii rn si, ca alal.-' itl lidicrilrx' "",lotrrJi-Gi'ctm l" l)l(r()tr l a rrilu', in special a llruscbitLlui ;;;;;;-;i;. o;;"}ii (x)ltvtf'gr'rrl.r tr ' rl.'omodal a1e Sr lupilei, i'ncrioare ii tleficite in )ol,ilitatcp. -ebt{i il" krzitrnilt' i()tlir'Li excepl a I\''-i p""".hii .In A'r:oli;"ll-a' rr"t*lrl.i in tirtrli.l,t' trtiq|r'i.r'il' ;i;cdrile t1eurmirile pot ti pristri't^e, ;;;';;ljidt'tit irr ParrrliziilrL'v.r'1" t i"t oinitt''" DiIlopia 1'o'rt''Ii 1r'oz' i.,i."i;" ttu ittrlttr'' tlirlitqttl't satt vestibttlalr't opl orl tiiri",- ,st,it,',rtarea 'irLeiic,-r lerl,ical. Sintctizincl4llpjgtlinlitr.r':l1Ltr.i,Il{'ILdcr'(]{)U|r)iLlillli(jiiil||,iu'll'llxIiI .,t91, tttltti'l'l'trittr'l'' lsi'ciit,ttttnlsntiIrrlti tttttllr,rlitt lloi,4elqrl.iculitatosir ,,ris,,,i: r'('gt,rrrlrti s:rtt ltttpilltt'lrt tliirrirrrtleit : a,) ltit'ttlctt'it t;ii;ii,,;";i,,t;irlorii (1r)rr\'('r'gt'rr{'('i sittt ; | ) (' b) sp:tritrr i;;;;;i;i,;; i'i;; r'otr*trtgr:til,ir; I I I III I |)|||1 I I f1 l!rlrllrtl' tlislrtAtttlls i,'r', ittr,lttsit,'ir't'rtlizia vitlirrllrlt,ir riqoirilol nisl,rrgrrr
r i: l

I l!1, . Sl lltoulnele Lui FoDiItre: /.l .L 'r!l l l i rrh l rl i l ./r .Ir l&l!,ui\,r r lonlnor ii( oculosnc) jr .- r ilr r ec ol ti c odr dur e lr ,) vr lt. por tjh( xr t*; Z _ Si r r tr dm r t l Lj i F ov i l ) c p.{nr nel l rd rn , l .!.h l )j i,- SLr ||,J"nl ' r :ir ' r ,t rh L l i,t r Ir r yn{ ; ,t t!i ltvil. l) r nr l u.r nl i r t i nfc .i or , ' ' Ir t

rl ,"r i l r{, i- lor r ils l) t . r ,l) r l r' l (,i l ,.l l )l i tr1 l r,z i rtn i i . I)rrn rl i zi l ,l :tri tt,i i i r,stc , rl c l i l l oq11 r,l r,l ,r r.i ('l t l' lii,it r r ; r r ' r . r r rrl 0 tr I rr,I rr i ; I Ir,; I i I r, rl r' l rrrr' l r.rr rr1r rrsl l r' zi rrrri i (l rol i rrr vrrl i ;i l ,t rvo l lr , t lr , lr llr ( , 1r , ;rrtl rrl i z l rl ,rr). 0 :l

r||rInrirl.Firrii rrifl. vrlIrlr..( lrii. (1r'iz('l('rt'Il(,{.if.rir,|t{rr rr]n)(i(hl(1(rllll{.(', :rr(,ti.li, slttr^rl. r gil.r(t.,.irr\.rr,l,.ir. si (1. r,,t.ilil,, trrlli,rr.,,,.r rlri rrrtrrStiirr(,i, Ar'fhl" irrlrlirrrc.sivi 1lr,,v.rri{,i rlrrrl.zirrri iriliac(r}l,o "r'iz. rirrl 1r'rxlrrsr'(lr'sr criilrrl r.or.l iro trtrr,ltrart pr'tr l lrr rrrJ;r,iirilc coi r.iugat ci (rlst)ilatliru firls1ri, irr- lr;rrril,ia uror urisrr:ili (x,llrlrc l,) ) r,lipidc $i . -in lr;r.li.(., rtislilg,l'irk'sntt nri,rr.l,r ri.c, specialorizc,.ialt., tllr. qi v-ortical'e srrrr .rrrlirl,r,ii,ir'etliat inairrlr,rle a fixa un obiect (u'tel de,,tremordo lrrr'lrxrrrr"'). ,\r,cste.miqciri pot fi acompaniate de tlemor il capului. ()lrr.(,k)lriir rr fos1,descrisrli,.in dir-e'se cncefalite, iiinel prod'si, de i6ziuni rrL,olivtri bulbar.e;i a,lenucleilor ditla{i din cei.ebcl(Jicnder, 1969i. l,') ,ll i.oclouiile ritmice ole globitor oculari pot upiire:l in leziuni ale rrtl l, l i rIirrr:ttrlirr.cerebel. rrle ruclctrlui roiu. oli\-ei' lrrrllrale si7sau ale r'r'r'rrr1r.lr,r' lrrlrunorrrbroolir-ure. Se manifesti, prin contraclii riimice ale llnlrilol or,trlali ('u o flecvenld, de 50"-90 pe lfinut, clrora'Ii *" o*o"i*rii, rrr rr.r.lrrqi ri1,rn,tnioclonii ale.palalului mdale, ale f01ei,Iinlbii, faringeluij lr,'r.rrr'r('lri, rl irLl'r'lgn*rlui si chi:rr ale membrelor. Dc 'rrrrilte' miocl6niile rl|,Iri|'r'.rrrrllr'i silr1, $e'de diferenl,iatde nistag'mus, i.si. o 'ri' elaJizi, clinici rrr:rrlrllrrlli rrc alllri, cii nu eristi, fa.z[ lelti_ (i ) p|in ;lqilatiu alobiloroculuri,(,,ocular bobb:ng',) se craracterizeazii rrrrlr'rrliirrvolrrrrtrrr.c sincrone ale ochilor 1n ios,-cu reyenirea,imetliati in A fost- d.escrisi, lrrrzi{io rrOr.rnrlii. in leziuni iiisiructi\-c intinse alc protu_ lr.r:rrr(r.i(Jrishcr,19e4).ln leziuni ce,rebeloase s-au d.e"qclis mi6ciiri ini-oltnlrrrr. si Ir.IrrlrrlIrr,u r.i ni$ciiri oriznntale ale globilor.ocdari, cu apa{iti:r in r,r(,l|||i, ilr llrriDul lirririi ur[ri obiect. :i.1.7. I'roblcnre de diagnostie etiolo.{tie in palalogia sistemelor 0rtrl0|[{rI0tii irr lcristl tt ,prinriltalelorrouze ale olal no,plegi,ilor prezinti, .'l'r't,r.r,rt'rr rrrrrL'osr,bilirrlr,r,trs pr,actic,cr rltale procerld.m la u"sintczit, etiopaiogenich (rlrrpri .,\r'slrrisi r.olali., 19?? ;i Popor.iciu si Fa,scu, lgg0). l)oli. .inJec!base ;i in.feclios-ulet gtce acute si srlbttcltte: ..:!..1,.7..1. rr) || rrrrI'I irIi I Ir 'r-i.riticepr.imitir.e(t-pidernicrii, z,,siiriani, ubici, prin arbo_ .1..). b) )lncefalite necundare(rariceld, vari'olii, rrijeoli,, 'r'rrsrrr.i 'ir'o1ico infectioas:'i, |rr.rl irlili rlrirl'rnictr, n)onontl'.leozri gripi elc.). c) Encetalite rli. I''r'srr.linl*(iiilor generalo Ifebr'i, litoidri, scar.lafini, lrise 'conYulsivd,r iir,;rIirrltrrii, ttrurnii, richetis jr'ze, malar.ie ttc.) al) Nc.11ingite ltrtrrt acpte sau rrrrlrirrrrrlr.(r'cningococic5,_.}ncumococici, t uber'cuJoasii,, s#itis rr]o.niogor;rs.rrLr' rri..) tr) J.)oliradic,loneuopa,Lii (polirad.iculoirer.-ritd, Guillar-nlli'r.(t1 r,{li,i{'tk)z(: prrnneoplazice etc.). f) Nevrite interstil ir}lc secunda,re rrrrrrr irrlr'<rl,ii rl0 r'ccini"lato (sirr zitc,_o-tite, ostei1,e, abceseetc.). g) Nevritc rlir..ltrslrl .u',r' h,li . inlcc{,i.lrso.(tlifteria, botrilismul, tetriniiiul, s.a.) lr) Nr*r'il. irnr'ro,k*c,i.. (lt.slvlr.crinale: asa-ziscle rccurenic,ial6 ,,p,r'aiizii
r't I ll( J t ctallli It 01 c.) .

I) tl l r tt' ttttt l t' . r r r l r r , i r r I t r I l i | 'o t'i tl tr l tto ttttttttl l tt,,,',tr l i r zr ', i t'l tl i ttti l l i tl i l 'r r o l 'l t ) ' r ')
I r l l l l l l l l 'i i l n\Z l l .

'''1 'i '. . 1 . 1 't '''i u tti l .I|!( l t],ttl ':|||Itt|',l r ( !( 1 i h r n t.,l ',t1 ti i r ,.'t'.r Itt'i r l r 'sl r ttr Ir . u tTo l 'i r l i tw ' l r q t t c l t i r r r r l c l r r itl . i l t) tl n tn 'r i stttr '.'l \'' l r r i i o r '''!'i r r r r .tci t- u 'n r r :i "w e l t r h ' D "z i I i r t i " |'r r tr r { i tr i l i tr tr tl 'tl o g i r '' o si ttr l tl , ,t t t ,t , l i t r, , i rl i r u , t) to r l u ( ' 'l(i il 'r i 'l'ctr l l r t'l ; r l l s|.r r l a \1 .( a ) l r r l r '1 t , r ' 1 , t , . l l i r '. i r t r , l l i j i x; ( i 'g r r l t 'i N l r r tttr l . t9 6 l l ;

t'o!'i ltot'vii octtLrtttttl.ri . , i,i,'l'., lrrtri, l.9t.r, 197?) : ctkt untirioare leze:r'zil I lt a ltt-a) pcrethii ll, ,si tlltntttlt't tI i'It I ttt it It ,,,,,1,,,sr,I'ti t,,ttiu.rl superio,uii Lok)rl t l)t1\rllrrl la fet to!'i nervii,oulllulr trr;','rrrlrrrrItri) ; tde rniitoaiilezeai5, loztt"tr'ir '1,, ' ii',,'ri, it,Jtilirormu:i ale trigerncndui ; uieltisrnt'lc ptttteri'oaro irI l()lrrliltll'r.' trigeruetL rrel'vul (VI) ;rteru oculomotor rrr r,lrirrilr, n('r'\'ul $i ,,,,,;;;;i,;-'_,; _i rrri sindrom claude Bernard llolner ([t'ziurLet,1rrit,$lo;tt"Zl\r pttl lt'zrt ttt s'upt'aclinoitlieut aarotid'i'ene Anet:rism,ele ,,,a,,'ii,",'*i,*",t'i,'rrn). tI it:Qrt'lt1 tio nt'lt urterd de Att'eurismele comtltt. ,,,,,,i ir,,lal tt,', t'tLl oculomotor plin plozii' pllptilt'llii' lrlr'ftirtlii cloar atlcseamanitesta s1' ,',,,,ti,,:;,,,,r:A 11rL nrtereibazilurt poi protltce jrlr:rlizii txrtttltitrrt'l'r" rrr trrlitlr'i.. 'lnrtrisnte[,e f I-.r,-ia" d. hrrllt oLi ttlt sinrlrt,tttI'rtritt:trtrl ,t. ,,,,,i,".i,i1u,, rr lll-.r, .,i 't'r"ntt'lt ^ A n.ite ie tt.iJeritcetiutuqii' t't ' ' i;;;;,:,;,';i; ',Lt ' ' si tl tt',t,u-r'iri,talirr". r r ( t olido'( t t Dcr t t oust lni ( Llt Pr t t u^. t ) t 'isl e
tt,l ,rl r r ice : t1 -F\'mtrrri clrrtritrlto itlt' ltrtzt't itnle ctalt it,cttctful l!.1.?,5. '1't'{trunttt in. n) nlllzir r ' ,,,,,,i ,i i r,i * i l * r,i r le or bit ei. b) Coniuzii cer ebr alt '. I ) c pilt lt 'r ,

, , ; ,'l;;:;ii iiffiil;il

(x'l'1rl)rllltl ,rrt ttltlltlizii multiplc l)a,l'ttil'lc (le oculomotoli' ln coli'ttzilt r lili'r il") gr r r r k inlr '11'\ 11( i. ( ir L ,.,, 1." ,,," i ,:rl ,, i'i, 1, : , l', , i; ; i'l ct r ob'll, pot I i r t r ijlo. it t r 1c et : r 'j lt t t lr 't t t t . t t c*it r it 'n. I t : r . t t t r il. ," ,' ,,i 'r',;;;i;;1i,,";,;;';r.ir,t,: .,,' u t , , i, , , , 'r , i' it r u v I rr pc.'(1hii irl(' trururri iit oi vt, ,l-n'urteo..i i.,; ; ' tl i i erl('ltr 4l hitlrr,'tlinarnico' , 1 l,lli'rl ttrcll'al posttlrlumal.it. d-) nlecrnirtrru vr t t i: t lt ' lt t r t i ic{' ulnal 1t 'r 'll lii pcdl, 't t ') o{ulopi lln( a le. r' ' .,' ,u,,,ai ;r," .i " l'o"t t l'r

pi l"*

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i' . / , , r . ; ' . . lit . r t t , l .i t,tttl r.u t.l trrl ttl rl ,,t l t rl i .l ,.i l. sn.hsl .* )tl .i rrrl ,i l ;r,l rr i rr str.rtl . ,o || IIr |r r . ||\ : || oli, r l p rrn i l ri l rIrrl r,rr rl r. rr rl rrl ri l i r ,orr rl xrrroilr,i r, si sl ,rrrrrrrl rri vr,A rr, l :tl i t ( s it t r ; r r r t i. s i l l l l l n l r,i ' rl ,i rtrr.;rl r.r..r' r.:r1 Irr,{.i rrr,h.zi rrrtr.:r r,;rrr.,, l ,r,ul rl rr :rrrl l |tit t l: r ( lr . t I : ir il I(. :l I | | | , | || .|| , |.. A ..l l i .l , s I I L { | | I I |( r, l r. r.rrl i rrr.rgi | r. | ;i r.r,l n ;| Jr.r r(rr r ] r . s t r t it z r c t r l l ro d u c | o rrl t;r(l { i tr l )u l )i l c i , i n ti mp u) S l tl )sl j A l | i ,ellt, rl i " i rl i rr.r ' { ilc r ii, r ir nlrr,L i " n mi rrrr.l ,i r.r, o i i i l rri ;i . I)e cel e mai rnul to ol i , IIi rorruI| i i IIr ; r lo pup i l c l o r.s l rrL Ir' ,,,h r" (,ti c d o l czi uni rl c .i rsi l | rl ,| ' li ,,Il l rrl , l: :1 l i l' j' ll: : .' r,r , r ' . Z llllu r t p Sl m D a l ,tC L tl U i . ,\rii,s/arrlr l" cu)e ,,Jecteaad actiritatea pard,simp( ix(i si se folosoFtc ,.,\) .1 , D rr ) r ' r r ii, r 1, . r . ar ? rfT re n l ru d i n g n u s [i c u ] d i l c re n i i l l al aD oLnal i i l ot,d,,mi l ,i nto IrrrIi l : r li . . ir r l par a s i mp a f i c o m i m o l .i c e S i p trasi mpai i col i ti cc. l ri nl tc cr.l o 't)tt)u\ntputLu)ntmctrcp emmtim | physoswrnhLa (ezeina) O,Zi % Uo_ rlrrlr'lrr rrrrochi normalo contrac_ti;-madmai; ^) a pupiGlor

r l o tti i l tttl ti l c ( ) r l i f l l r r r r ti i r l r r i tttl r l l ,'l l ' r r r r r r i ttl r c r I i I t I t t t I I I r' I I I l l l o t r l r r r :r i o r r sl l i l i I,tl ' r r r i 1 ) r r ( l i ( i i sl l tl i t'.', 1 , , , t , 1 i l o r r s i r l l i l r 'l 'i r , t'r r , Ii zr ,,i ,,; '.r r l i l l tl r i l i i , i tt l r l r ttr i r r I sl r r t r r tr l tr tr r ( i t'i t l r r r r l r r tl r i r tto l ta l t l t,tl o t'l tl i l , r r r ,l i : r I i i : t I r r s t r ( ) l ttL i zr x:t- r l 'i c s1 l l 1 j ( i i l r o i l i ( r Ii Ii t'r ttl ttr r l t t , ', , , , r i r r i i , t : t l t l tr vi r tc Etlt t t t t i l i rr :t I t r I t p u r e L i a d ', t'tt;t'r ii t[t'l '1 t':l zl 'i r cttl tttl t l , \ , l t : . i t n t ( i t t , t ti l tttt:r r tl ,ti ,.l i r i r i l u l i tti i ,,l i e l l f{'l ( 'l l tr '( 'p a r a sl n l }:l '1 'l co r l l l L l l l l l l r r l r l fl ( 'r ) r r r N l l l |' q i cl i ,i kr 1 'l l 1 , r 1 , r , , 0 t r s l , t i 0 1 ti r i ':i l l tl r r i r l r ' i , 1 , , . , 1 , , , , , , 1 , ,s i n r p:r 1 ,i ci r ,.I) ( , ts( :l r I( r l ca , a n i zo co r i a p o a l 'c si ' l l l ':l l i l r ', , .

i , ,' ' ,,,,,r,,i i ,ri i i i r t r L inhibi! , ii a, ct r it r ului co'st r ict or , co. s{j( r ul'i'r ' lt 'zit t t r il. t ' ,,rr,,r.rrrrroL,rr[r r .Lizucor i: j calo sc accent ueazi, in t im lul diJr Lt iir ii lr t t lr il. 'i Ar ( 't 'il.{r r l( ' r l , rl l rrl ri t' r' i l rl odusi, de lt ziuli ale sir npat icului' in t ilr lp r x par asil) r l) r 'li( 'lr lr r i" lezir ii ,' ,,,,,. 1,, t,i rr,l r ir l cont r acliei est e consecinla idriaza (creFterea dium'etrultti ltttTtilo'r pesle 4'. 5 tttttt.) :',t.ti.,t. -/,I (lil'll1 il lrr r',,.rt, lr rrrt,ilniltj,si in conditii nolrnale. Astfel, pupila trstc nlai : r r lolescenr i' ll' m opi, I a ,,' i, I:r l ri t l'r r li, ' ' ,,' l l l ' .i trtti ulr ciilur t 'lt lit r ll i(t.t'i.a,f;(t Qrtaur(i,icii se nallilestri prin faptul cti ltupilrt' lrr oclr ittl ,,r l' { Hl(f irrk'sca' Inai mare decil, ]a ochiul s;nil'tos Acela6i fl]rroltlotr Ntr bilateral[', apart rt tttith'i:rzii li irr rrhiul ambiiopic. ll :rmautoza 'ui,t,,,i,,i,' l ,r rrtrrl ri i ttt l tt.

lfll''rl Ir:) rtttttcotl_na sollttie 2,5 7o.nuproduce nici o modificare ia o pupil), ror'r||irt:r. tlr (rzII iD care inervr-ti, r.pflrasimpatiel osteixtrerultd, m sihii -va'proriuco c,,rslriclr)t'i rlevin mai sonsibili astfcl hetacolinn 2,5 o/o _$! r,,rrr. rli, ri,. lrlpilrr.ri1 rll Ceg maj loloiitd .s/rslonld p,trusintpiticot.iiica esie rlt uttttt,ltt tt hldrobromi"d 5o/o. ln rimp de 40_60 minute de lt inslilrLre:], Ir| )|, |:| | | r,| , II |{' i . cr pupili normalii se dilrlr] la maximum. DacJ inervabia, :,rr.t,:rl r|i r'.ir. irrl reruptir rlilalrrrr.resfe tnici salti)b;:eati.

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ff;1t111.11('"_rlstanlelpe4rpaleclpd:doctiDitatp(tsi/,.?d/icdsicaresefojoscflc lll Ltritt"rti ula centrilor li cdilor inJerioare , (l tb aolire,^cer mri urilizari e,.tecoco;na4o7o. Insiilareade parru | ) .lll idri.ur(, tr)araliticii (patrlizia ah-solrrli :I prrpilci) irl)irrrl cir . ],, ]l:ii,li (i ., ''(.r t'rr,rlor' l qi/,surr rr, r. r r'liu nrtzenct.fll lr, ii i n sr cul conjuDctivrl produce, in motl normal, d ilai:r,rr.a , , , rr r, r. i i rI i i. a l(^zil[r-ilor centruiiri pulilal 'r'r 'irr sa2u1 'i itr cnre inerratia sifopati;n'este '1rrrr:rsir |,tt1rrlrr"ri. intrerupte in afarn, rLpatico' Dacri lozjulei estc localizati proxi la'l tlc grrrr*litl , t,,,.r,1,. .ir' l.r'rllli ..lr'\os corrtt'ril, acestfenome.'nu apare. Dacd,exisi$ o activitato ,,,,t ,,1,' ,r' lrtri thi: r ) a loat e sli nu I ie colr plclli''-il I t im p. ce o lczint t o r r I ilr t r 'lrrt -cocainei ( r t r r ilizr r t t zr rr r ;.r:rr'.rrirrrprri,i.i. 11'suuti,ef,cctuldilatator .aI r r r l cili: r l si r r elvii este slab. Se poaiu 1,,,,,l 1,,,t,gl i ,,ttlt ,(tgingiior 'o - ''iliali, slt t r li) 1tn'ytlktir'' ttptti, t.t tt't ..t..ltt')rtt.lIl gangliutt,ltri stelol cU 5 rnl rle procain:t hictl"ooloricil ol.. nelini$" \t' tt irsibla La lnce4ut 1,,',r,,,,ri ,,r,,,.,itr,,tiiirtr |'oD{tr(|| lrol rtrl(., lu r luschii cilii': i' so lr it 't 't lt rsi lt t r t t t t t r r dit cauza aCtiurii parasimp;_ l)ltpilrrdevino miOtiCd ,,rl ,l r ,' tt Il i tttk' r 't r a f i a l: ibr dlor pent ',[le,nr
lrr' rrlrrl

l.,l lll rlurlo,[.oq.i( tt.tilizd,rii probelctr colirelor este urmltoarea ; a) Dd,od, lt t.t lt t ltr t :tlt'.tttith i.atiLrii, se ta testa in primul lincl cu metacolin i, 2,i t/o. Api_ lr{r:r pr;rilrr ( r 'lsir.ic1-ieidemonstreazL o leziune parasimpatici:" Liisa i)rriirr',r n\:rtlltt puprlare ]trage atentia asupra unei Stiri de excltatiO rLrrrrIrrrIi.ii, r,r*. |.rN{r ti confirmatl printr-rin-bkrcai aI ga'gliouului iiefii rrlrrl,r:, :r.r.,t 1,11,('r{rler api-(ind ia pupilei)'; ni \icA pupUa isii ,co-nsirici r/,','./,,,,..sr..\1',sljrrL.primul rind cu homaLropixd ioo. ln clzrt in car,l rlr.v||r'.1i,:r11" mrdrirtici, rvem dc,r frce cu o slare d.ccrcilllrilitrto l)rrl'rl:r ,l' jri:.:: iar rtaci se md:e$te pu1i1, l,;ll:l ll :l:icu1i, le aflaim in fa,1aui;; ir(,,rrr, r'r ir trlrunulur simpatic. Du1ri-trecereaefectrlui homatropinei,'pulenl rrr'{ r r.r (lo{liritril,.Darli pupila se dilati in mod oviclentr probibil li-ziuaca r,rrrrI rrrI irriii,sc ir,i'lir, in caclrul S.N.C., iar dac[, acest fenomen nu se Droduco, l.zrrrrr.rr s. grist.rjl{' irr:r,ftta S.N.C.,I* nivel'l f.ibrelorple- sau posl;gangliotrrrlr,( N1r:rlrtirrr, ltltif)). :.)..1.,\.,:j. ,lti:rx:urit (iuHt ,lit lt,t, ytTilard)-'ln rnod rxrr.rrn,l, pupilr.lo " rl('r(x.'rr\ii rrriilirrrr' *r,'l rrglrll r stirntli. llacil prrlilcJr,irr 1i I0rrclirrrr.nzil

rytlegie internd,)' iir ilrtr''o llttinrri' trzi jjol',sii' alrrtlii' fiorrrt(r ,t.,,,.. 1,,1:til,u li('(ri,{rrrzil a pereihii :r, III-n. Nu toli,e lcziurtjlt (1;:rr\r ,1, ,t,r,',"ilrrr ,",rirpii,1r'i, im plicr r I ibr el'1'r r 1li1'r r ''r t r sit i|1't l: t 1. ( l''llt lt t t t r t l' poi (| ( r,rr\| | l tl l ol l l t) li( l'Ioonlult ' , qlli'i1'r ll"' i''pogt r t lit r ii st '1t lt it iger - Wr : st pir a, l llult . 1cr r z. ro rrrr,l .rr l rri l ,)rl , rt lcr'itrttrt tl.ttdcfitii it, l,tt't' i ,t.1 lll .:l(lr..l rxrinpltx*lrLi nu.1ut1' 'cUlott'tol.t'tt plt llt silr llr lt lit 'i l) it t I or t l't lt ' o noof il] i colllir i r l rr, rr l l l -rl , i )oir t , o I 'oNpo{}lll' | ' rl l trr.l tl | (' tv| | | lI it lr lt t |olr t t t l; t llcont t t t t l. lt . it t t ] t lsil|ilr r 'r 'llllut t 'lt sir t t ; t ; t 1ir , t . , . llt t , '' l t t ir 'r 'lt t l glit t uI ilr t r t llt t ir . ililt t ,'; i ir I t r r 't . yi|. r t 't . ililr t . i r' r , | ,.r| | .i l tl i ' r,llt |t l st llt lt l': t ,llt pl! nlr t f ( l ir r so{i1i r k'olilr ilt t olr l'gii li( ill1( 'sr r t l( 11( 'r lit '( l ,rr' :rl i zi ;r lr r r lr illt r : ii, lr 'llt t '11i, 'r , it lt lt r llt lillt it t : ,t, , 1,,{,ti i:rl rr sisl, qt t r llr r i lt ot v( Js, l'( ) ll( ! sir r r l, llt : 'i, zr r lr ir l( lr l| \ 'ill ( ii' ( , , ,, I.rl ol xrl i rrrt t il't illt ,lt t t t r , t it r lt 't r i, |I I ' t' I II I i 1i I llo$1'\ 'ilc{'it Li ' t t ( llr li lr li llll n: pt 't t zilt lr t rt t lr lr ilt zlt ' lllr llr lif it lil ' ,r l , t r.l c. l l t lllllll, ( ! <r lt zt t t 't t 1,,1| | i | | | | l { r)| | l ' t. r i|'llI lr |ir t l( , it t t r ilr lr . lt t t t it t lil, r '. Sji'ilisI lI lt l( |lljllg( t vlt sr lt t I lt t 'lxt lt l, t r ilillr lr ivii 0s1't lI ipit r r i' 'l) ot t lt 'r t t t t t r lt ilt t liit 'lr tlr t 'lt lcr r.,Lrl rzr o rrri rl t'ilt zi. p11, , "11, ( ! tr!r rl rl ti i l z:r lr olr ir ' I i l'( 'lll: ll'( f l ll, it r si'lr r liilo l( n l ' I I t I I I I tI I t ' ' | l i d| ' i /l .i !( 'Tt ur t l|, i|'it . iilr r r r t l, t 'l'i, i||lilt I i1iiiI lr , r lr lr . |'lllr t lllt |, iilt , ( , lll'|ll|1|j||( t I r r r lt lr t ( lr r lt 'l \ \ r 't t r ickr r ) ' rr lf xr r ilgi( r iiir lllr lr i( r ilt lr 11' ,,Irootrrrr' | rt I o1r it ll( |, iI it t li't r {illr Hr r l rri ori rrtr{iilr r t r t t t t l, t opit t ii, t 't t t it t plt ci' lr t i't 't t t t t ii lllr ( 'l( ! l) r ) li l'illt lI t lt llt rl .,,trl tl | | r, l ,' l rt t t t , s 4. t 1. ) llt ( r llllr f lr llt r r lizii lr t t lr illt t '' r 'r t t t t ir lli: r zlr

Al i tfr'(l{ f r t , f r : llt i.s rilr l i l l g l t,l ,, tr. l x ri tl n r l rtl l ti tl rr q tttt,i :pt1xt,i t / 1.r,ri ,,rf4 i ;rr , rl :rri l , rtrr,r.I;r I iI r r I lir ir l) ir r ( ' u r l i rrrIrrl t,r,l l r,rr,l o r. i tvotn o /l xi :or,/)f//r r./i ri (,1 1 rrr1 ri l rrr,r,, 'l i'.

7il

r l('zirr,ilc nuclrarer oftalmollegia e..tc'riri porrle Ii completir,, i'sii..irr. ,,1 ii rr rL' rrftnhnoplegie.intcrnri. r\c.rLstadil rumil rplre r:rreori sillgurii. Ir ) l[ idriala sl/asticd, e trtt co'socinta uno. lezinni iritatir-e are cr-r,ir'r rrrrrl,rrlilr.l)upilo-dilrtatoare. Acest fenomen a,pere in contextul sirdro. rrrrrlri lrri Portrfour du Pctit,. care cuprinde: midriazi, lf,rgirca farrloi se asociazli ou vasdcorrstric{,io, I rrr| |rr.IrI irIrr ;i u;olr.ir. cxo1tamie._LTnc.ori r.rir|'r'r'rr 1.rrrpt'lltruii qi hiperhidroza lemifelei ipsilaterale. Midriazr 'rrrr r|r' rI| l)lIirrrri rna,rc,nu siltt scmne_ de paraliiir., ial reflertrl fotomotor ryi '' rlr. r,orrvr.rgcrrlir, sint prtrz,ente, sal doar uqor diminuate. ln leziuni progr.rl irir r', slrrrlirrll,.clirninrr. dc irita'fie simpaticil trece intr-un stadiu d;deii(iit, i irrrptri i. si , l)irrj1iir consecutiviia miozei paretice in conte)itul sintlrotn.u lui ('lr,tlt l, ) n.trtd-Ilornr:r, crne estc lniti stabil qi mult mai frecvent intilrril,, Sirrrlrrrrrrrl I'or.r,l u,r,rdu Petit se inLilneqte in adonopatii laterocervir:,|r,, lrri llrll lr ctilo:,lnei lr,r;rlrr cgtvicale,traumatismo ver"te6romedulnre ocrvi(xr rl.rrrrlr', irr .ilr(l{r'ul si in tubelculoza Tirfului prrlrnonrr, in ttmori mrxlirw Lirr:rIr', rilirrgorrrirlio,tnttfltlite si trtmnri cerebrl.le. llll l,i:irrtti (ltt cenlt'ihl' gi crl,ilortu:perioot a .l ,l Ilrrlr.irrzrr o)r!irr*1,i oxpe.imentalprirr inllibitia co]11.,1.i 1r.rr1,'lli ,lIi(li(,r',.ir |r,zrrll,rr.l, lrl stirnuliirii cortoxnlui ft.oltal !i :r,Ihip.1,rr, 1rrrIrrI.r..rr rrrlrr. ,\lrrl'irrzrr lrrrrrrr .sii' rrlri mruo tlc p:rrton opusil stirnuliiii ccirtiorrlrr, rrr r,lrrrrrl,r.rl. rrrrr r.i I rrrrI:i lr0r nol:rl;i,trtl in stimulirr,oat hipot:llarnusul tri.

; rl I t . r t t i o l f I t t t l to l t t t l l t i . \ l' it t i . , lr . r ir r t ( ' |, , : r , l : r r , t r z , t r r i l r . ( , i l t t ( , \ . t i J t l l ( . t l i \ 1r' l.r'ir .M)lirlir il r l( ' r ' r ll, r r r r r , r l, r r . lr . ; , r r 1r ir r r r I i r r o i r I i r ^ t r r(,r Jl l f ( i l ) L l r l ) t , ( x n r 1 1 ((!l rrrrr ':rlizir' lzrlrrlii r r r ) ( ' lt f ( ' lr ir r r r r r r r r r l' is r r r r 1 . r | r l r l . r 'i r , r 1 , ! r o i l s e til\.orrolrsi\ rr' if .lrriIrrzii, rli'o lr ir : t ' i, t t lt r r r r r li . it lt r t lt ilut i c o n l t l t k i . o ] n i ( t r i r r , z r i p . t l r r l i i , i ( i L ir' ,rrrr1 r)t,i{f l),ll1 r ! i- L lr } la. , ir r r r r r : r . , r r : r _u1|Ll rr L o p l c u i r i , s r r r r p o l t t o , \ i t l t ( x t t t t . p:rrri 1, ., itrli\.ti, . ; ' r , , ' lulr . lr r r r . r r r r , r it l. r lc l , o i l e r i o l l c . cl:rlliclre 'l'r',lllrrali$rni'[{] o c:11'rz;rco'nun:.], a !fr,r'illiziirr)r' 'cr)rrzirt; 1,rilrili*i'. Slirh'iilza lloate fi con-(ecinla, lczririi dir.cte a tlunchiuhii (1ercln.rl, rrr rr .rrFirrrii, re-qp{lctiv a cornplimirii neryul r1i ocrlonrotor cor lrr.

I ' r r r rr ' r , ll. r| | |i |(' | | | ri rI r , rr, r, l rrr r,i )r rr| r,rrr(N . rri (rr.rj rz:r rr' .rl rri r..t, ' 1r \r'r,r ' t r r r t l, r r r ( r , I l l l l i l )) rrrr ,1 ,. , r ,n ,l t r tr tttti l trl .r,ntl i1.i i t Itr s(fl rLui l ti (| l tl

\'i l l r l l l :r l l I t ) l l i l n r l 't :;tu tttr t i rt I t rI r' t rr t t t rr t t rr ( I t I | | |r i I I : | , l r i r l l l tl i l l l r 'r r , '' , | | r r ( ) 1 .r(l ( . r l r . r r r o r i i l i , i r r i Itt;r i l l ttr '. l l r sr tr i l r to r l ttr r t tr r r r i r r l l r r r r \r |r ;l ' t' t ', r r r l r ' I r . r r I o l i r r Ir ' :r l r . q i l r n r r l tr i Ir i 1 r o l l r r tr 1 r ttItti ( ;\r ';r 'l r i 1 1 i ( \r r r sl :r tr l i tr r "t r r . l ! r / r l r rrr, r 'r I r . s i i t rrr { i i , tr r i t l l i l r zl i 1 r rirl r rItl r tIr i 5 1 r |o r r l tr i l r r o i i si r l r '|l r tci l , 1 , 1 , r ', r . l r i l o l l l l , I\', \'l si IIl . l 1 l r t r r i .t. tTti l r l tl i |i r l r , 1 i p g tr ttr tl I I ri I I , I ) I t I i | (' I (I Ii ttl tr ti r ,i r l r r tr ':r r 'l r r ' 1 ' r r . ': r i i , l i {, i r . i r r si r L r vi tr r r r i r |r 'i l L i r r r . r tr Il zl r l L r l ti r ,l 'i . \ f r r l l i r r z r r i r r r i r i r 'Ii i r l i l r i l i i i r tc[a u tTtti t, M '( ti ( r 4 .ttt) r tttti !. tts.l i r ;t, ttl | , , l . r l \ r l r r : r l ( ' :.tk' i ttl r t,ti ( tt!i i l o r u l t:o tl i a t, ( \1 b ( t]L i l tt) 'i t t ti l l l ( 'l l r r l l ( ' fl /r '\ r , r , , ( ) r r r i r l l i l r zi i r r r u r i tr u tl i i tl r l r r t i tt xl o 1 ttt,la r .n l i u tt ( ,l r tr l l i ttt,r t '.i l i ttl r t r r , l '1 1 , ,) l f l i i D r l rttl tr ',r 2 i r r r /i fi ( l h ( !l n tSto L r N ,l r ttl l i l i t' l l ttl tl e l ) 1 1 'zl ,r r l r r( ) r r r r r si r ':r , , , r i l r : r z r i i t r l l ,zl r r l c i r tsl r i t'r r l i c a tl i ttci i . . '. l . l i . i . , ', , r r r . r . r 'i n l i 1",tt., l,Iit ll t t r' 1t t t I r t i 1 ;ttp i l l l t'sttl t i - l ttttr t) l t;tl tr | r ':r l ll i o .tr r ,( tl i r r ti l ttl ttIr t i I i l t - t I it tt l r ';i u n i l o r i ti l a ti tt' It'cti i .l o r 'p 'u l ti l o u n :tl 'ti r :l o ttr : ( l ttr r tsi tr t ( si l ttl i ( t') . r r l t':i tr n i l o t l n r d i tl tl t ci r ,i l o r p u p i l ,o r l i l tl a l o tr tr

i n .l e r i .o a r a o ,l .t ct n l t i l o t' 1 i ci i l o t r tl c ( i {r l r tl l l l l l i co ttsl l i o l ,o r r r i l l i o . u s,p r r si i cr i p l i tt Iczi u tti i ti l r tl i vt 't ) , l , r : r r k r r s l r l c o 1 i 'r r r l l i l so l ) l ) r 1 ( ' i ttl i l l l i i r I: h e r n tl t'l g i i sa u l ,l l tM r ti l ) o l l l ,l l l r '. i r r , r l r r l i l l i r 'p i r k,tr ti r l i , r tr r r i n g i l t . i ttl i 'c1 i i :tl c si r tttsu h ti ( r i tvt'1 'tl o s. l ( 'zr r l l r l r r l r : r r r l r i l l r r r r , l cl l tto N , l ti l ) r ) \i ( ' r ,r 'tr r l r l l l '1 scvt't'i l t'1 c. ( ,Jr tttl :ttto v q i l i ttl r l r r ,

l r : i t r . r ti

t,r,, ,

('lursi(I,I ()70).

ti ) ') 'tt tt t ttt.i I t' ltr)d)t, l.r, rruri iiltrs (jcle srlratdrtOriaje, e\etcitii el:rtl,, ir , r r l[ ir l]rrl )j l { ri ,tl rrc o ri fr" u vrrr', ; r ) , i1. l i n s o c i e l e a de rnodi fi ci ri a]e aaLi vi l ;i ,(,i l r rr.rrrl, ;rrtr :rlr. r'cl'ltrrclol totornotorii. S-a flescris midriazi c6ntralat,rrl*iir rrr trr r r r or , lr i , { r r l: rl( ' $ i u r i o rn p o rrro c c i p i ta l e .A rs eni ryiJl otez (19?1) au d(,srt.i } r ,.r'.r, 1, , : r r { . 1.r r r . r l] l i i fi ri l rrrp i l a ,rc ; u ,) i n i ,rL rnol i l e i rontal c: mi ozri i psi l rrl ,r, r rl r.. : r r o, r ' l; r lr t l ti l ttts l o n rl ,i o l U tri m trl :i ; b) i n tnmOr.i l e temporui ,, (i rr r.', rlr . l. r , . ir r r r r ' : r 1 r' rrrr.h i rrl u ic c l rb ri rl s i tu de herl i o t1e l ob tcmprl nrl ) : rrrrrl r r : r z rrr[ r r lr l. t r r l i ; c ) i tr t,u l i :l r)ri l {o ] trc i p i t:r,l c: mj tl r.i azrirl , c pl r.tei r rrprN i t. trrrrr ! r r ' r ; r l) r t r ll tto fi l o i n fi l ti rl ,i rre d 0 ttu n chi cer{!brl l l : a[i z0rrrrIi r, r,rr rr,,7 r ii t r r r ir ir il tz i i p s i l l l rtftl fi (i 1 r ? 5 o 1 , (1i n 0[z]n.i ); t,) i n hrrrnl i otrrrrl ,..tr.: r r lr r r : r l: lr r ,ir r r u rl rrrlrrL , i rh ,i l i z irl , e p a rto :t, l czi rrni i , l l pi l i rLc pl rrl el r, rrl rr* 1, (l rIrrr . r r r r r l r |' pI rrs i rrrrrl i rrrrp o ri )s i i n fl z | , l l i [al l -r, o rni d.rj rrzl iI r i I:rI ri r.rr|;t, c r,trIrn l l ; t) t' l t l trr ml l toi ttncl c sul xl rn,l rl ot11,{ .l l i r,: Ir'l r lll( \ r ' r r lr ilr r r IIrIri trItri trrtrlt i: r z : riI s ilr ilr ' ; rl i I g ) i tt Itr^ tl rl o a tl c l c s r tl trl untl o rtr)tri ct. : rrri ,rai rr!.i r
l: r | , ) i l l : r .

stl r tl r r r l i r ',, p l i tr l czi tttr i r l c ( {'l l 1 r 'r i l l ti ;i ci i kr t l ' ) i l l i o : u . ? a l tl i l i ti i ( '1 l u 'ttd l l r u tr l :si tr L n tn ttl . r ttl tsl l t l r l r l i zcl zi i r ,r 'l l l r i 1 , '1 , r l , , r l i l : r i , l r l rr i r l c l l , 't t t r t : t | i o r , ^, r 'r r g ttsl i r t{'r t Ii ttr l l 'i 1 ti tI1 tt'Ir l r tIr isi l l l o l l r i i {.tto l l l l tl tr r i r '. A( ,|, r i ,r l , r r r r r r ' l i s c p ro l r r sr i ci l r : r 'tr ,sl t'tt'r t rr r l r 1rI i i t I r I i I r i i ( tt l l r x) l l tr ) ( l l l l '( ', \'l r sr ) tl i l :IIr r i r l r r r L l r l r r l i l l r l i r l i tr ci , r ,o r r .i r r i r t,l i r t'i si r t r l tsr 'l o l l i tr r i l tl t', sti i tl o r t'r l r tttzi l o l r , , 1 r , r r r r r i i i t rl t'r r o cr r l l r tr ', <.r 'r 'sl r ,r 'r 'r Ir r 'ttt1 r ctr t1 tL ti i |j i st,l i t[l 'tcr t l t i l l rfi l r rr : r I rl r l r , r r r r l ', l l i ( l c i l r ,( '( '1 t[j l r r t'l r . l tt;l i l l tl tl t tl .c t'ti i 'r ti tti i tr ti tl tr i ctr tti tti t l tti r l tr r r T:r ,l r r r r l r r . S i tttl tr r tr r n l ( 'l r r ttt[r ' Ii ct tu i l tl l l o ttl 'r ' t'si c r l l ct'l t' ttl l tr l l r l l l l , .r l , 'r I l i r l r '| 1 r i . l t \ 1 i ) t ) u : h i tl :i t'l r \tl r \ti o /,i \ ;r i ttt1 l r tIi cl ] i l l {) i .1 tl {'N tl i i r i i r r s( 'l ( tr }7 ,:r l r r l r l r ; 1 . , . r . r r r 1 . l r rIi L i i , si l i l i s, I,r r r tttl to zr t r tt'l "t't'i r ct l tl r Itr l {'r ;tl l r r r r l l t'l ( 'r {xl {l ) r ' l j :l l ) tl r i l ,l I' r i r r l t'o tttttl i . l ) r i s l ( 'r 'o i r r l i ,r 'i o i i r r ' ( si tttl l r r r r r ttl \\'r L l l cttl r o q , , i 'l i r ') . r i l r ttl l r r r t( . r i ( ' j r l r r r ) l r 'r r l \ lr l l i \ tl i tt r i i tttl tti l i tttr 'l t'l ) l t) 1 l l l ) ( 'l i l l l l ,i i r l ( f , 1 , r r o r ': r I r r r I r tIi I,i o i i ,r l c l tr u 'r ':t;i l ,l ) l r ' r r t Ir ( r '\'i i ( '!r l l i i r 'l r i l ( 'zr l l i . ( ) l ( zi l l l r t r r l ti ,,ttr r , ,i ( r l 1 o :L l { l l r r r l l l r l r ' r r r r ti o u r tr si tl r ,r .'ttr l i :tt 1 tt ' " , i t r t , r t r t t i ttr l i i i .tt.l t {'l r r r tr l r " l l l t r l r tr l Il o l ttr t'. I}( ' I ri lr ,r l rr' I l {' i r , :'i r '\l ) r i l l ( l tr tr t r l r tr 'r ' tr ', r r , 'r r r 1 . r t , t t l , r i t r l i ti tti l r tt n r l ti r l i l ttr 'l to sl t ti r tr tt r tIr ' * r tl tttr ttl tl t]t t( tr i t4 l t i n i ttt,',tt, r l i l o z;i . l r r r l r l r r i r l i r r r I ( 1 r :r r 'Ir i tr r ctr i tIr Ii L i l r r ,'l i , r r , l I , , , 't : , , r l r . \ u l ) tti t) i tt r l l r I I i I I I I I 'r ); r | ! L I l. r i l r l r r l r . , l xr r r l r r l l r l l . l t( 'l tti tto :tl l l {') . l } l l l l i ti l r r tti l l l t t r t h i u l , tr tr tr r l r i r .r i ttl t'r l r tttl t':tr Ii r r ttIl r I l r r l r l ,.i l l l i tr l i l i l r Il l r l i ( i r 'r r r ,r,,ultti l r ,l ,r ( i r r ' r 'i r tr ' l }r ttr r l I r r r l r l , r ') r ; { ' r r r i o {( vl ( l c Jr i o zr rri t r t I rrt i i t ' rr . l ,.i ttti l r ttIr o tr r III l 'r l I tr .:t$ i 'l l r l l i r r l ) 1 ',r 1 r r r r l r r l 1, I rLr rr i t r t t I I t i l j i r l o u r tl l ;r l l r tr t I ( i ';i t , r !r 'r 'l r r r r l l r r r r r l r i r r r ;r r l i c r ,',t vi t'r r l r i .i r r r t r ttl r l r r l r t ( l tr ttto t i l r l ctr r r I | | I I | | | | )| | i | | ( , ' | | I l ( ' \ ' I Irl I I I t ^ l l r ' l | | l r - r , | l l r ) z r , L tl tr r l }|i r tt|tIi r tr 1 i Ir r Il r ' tl ti l l l r ', l l tt( l tr r l d l o |i t\t tr l t l l l r t,n tt'ti n r l t r r l i tt:l r r l r ': r ' orl r r ; x " r 'r r ( i i l o r :t{r i ( ( ) . l tt l r l r l r , ttr tp tr l i i l r IIi r ttr l t IIi tttIr l r r r tl o :ttttr ', l r o ttl :r l l ,r r l l 'l 'l tr ) r l , r . : r r l r , f l r r l r r ) n r ( 'l l r r r i l r 'l tl ttr r tttl I I r l r.r, l : l l r. i I r t r r t t I I rt t t l i i r rI i I r r I Ji I i rr' I I I I I I Ir r l tr 'r t r l ,r t ,r , r tIr r r ttrr Io t i l r r r :tl t r l r r r tr ':r ,,r l 'tl ,r l , t|I) |) It,||) t I ' i r r t t t , I ( i .tl r ':i l tl tJtl tl tl t ttl t l i tttti 'r

( r I \ lr r r lili. : i' i l . Irrp i l rU r' :r1 l rl rl rrl ri Itrr,rurt,rr,ri stttr' r' r.trtti ,nr' tr sv rrrri r rt' { ,i o rl tl cri u 'lllri /rl rrl r' r i r it t t l r lit lr , l l :l i l i ti ,(,i t Iczi urri l ol rrcl vo:rl r, (,\r,i r.l rl -l rto l r ri r ()l u r . : r lr , lllil: ) . l l r l rl rtl ti l r ttl ti l l n r\' (, l r, l r ol i trl ,i l rri rl i rl l i l rzr,i l rsi l :r,l r,r.rtl tr l r rrllr lr lr . : r lr r lr r lol l r.l l l rr' Irr, Irrl ri l rrl r. (;rrtl r rl rrrl r, l i l l l rtl rrrrrrrsorrl 'i l

rtrl rilr r l. r ' rri i rr .rIrr I' i(i :l ;{ ,1 )r' i rr (' rrrrl r | { ()rrrr .i .i ot rl i rr i r r,.r,;rl :.,r,s. r' r' i rl (' (IrrI | rlil r) ii -l l i ' rf\l )l i r' i r rrrrz r (l i l Iro l tl l r, l ,l uki trsotr, i !l n' r1,fi ri u\rl )zi r, :r(', I I r|_ . |r"r'r' J r r ' : r I rlr i, il) ( ' r ll l l l s i rL (j r i rrr r': rr,r'rrrrr:rrrri rri ,i 1i rrrri rrrrrr, rl r,si fi l urol (j fnrr,1 rr(l r'r ir r ir lr r lNlil, ic i e s tt tl tr s (,tl l l n l l t tn : ri obi $l l ui 1. '.'.'l .,\ "/). lI rd,,iJ ic ti r i,le d,i,nanticii,p tttr)il.jr c ll 'l'ttlht.cdrile relleaului ;folomotor apar ca lezultat al leziilii oljcir.ci 1,,rr'(irrrrirlirr comlticata sa cale, fie peTea uJercliii, fic pe ccrr, c/r,ilir.lri, lr rrilrlul un etiurLilot mezeuccfalice. Existii" dozd eucnlital,i[iiti: .1.) .l'ural.i.tii 'pztpilure &sacial.ecu trulburdri de uerlere, L.l ulrriu.(, :r, rrtt)r' l(.zirrri carc afecteaz5, atit fibrele pupilare, cit qi fi].licle opti$f, l)(! I|:||(|r.L.rrIlor comun (intre retini,, rii zona d.inaintc:I coryibr g;nicril;t,i , \l,r'ri, lrr)do fibrele pupiiat:e se alespart cle cele optice) i :t\ I'u'rulilia pu?ile,rd, amaurotici, rezulti, dintr-o leziune tlistraetivii, ,r'rrl)lcl,i rr lctinci sau a nervului optic. Se pierdo rcr,ctia tlirect:-r,si corr '.rr,. : , 1: r . l: r lr Lm ir ri , l n ri m p u l s l i m u l i i ri i p a i t i i ochi ' ]ri i i rrsrr s,. ' fer.l al , lrr iir.irzii, r'.110(ilr' corLsensua,lila stinrulare; luminoasti a ochiului'si,ni'rl,r)$. rrilo. r.rniLrtorale, rlc obice:i prrpila F"stedilatati (midriaza arn:ruloticii I rr llz i.rr ), rrrl l r . llc r r r l r lr : lt c o n to d a l e e s te n o rm a l . lr) I'rrroza, pupilarl ambliopic:i apare in cazurile i]t care leziunilr rr.l irrr,i srrrr ,kr'.r'.lui optic slnt irrcompletc. Rc:r,ctia lulilar:i la I'ntirrl ..i. l..l:'i 5i p.rrlurigit.i, a'tit cea dircctri. cit 6i cea coirsensriald.ln lczirurilrr unrl;ril rrl(', (x)lll,rincfiia,consensuali oblinuti, prin si;imu1::r,rea ochirrlrri rirrrrl,s .irl. rr'r,i nrla.c rlocit r.ir,spunsuldircct la lurninii. pareza pupil .ii, i r| | | | )| i(| | ' ;r' i i rr iirs1,d.solisii iu nc-r'ritelerctrobulbarc, leuropatiile dlabd;ir*, r r rrrr r lr lir r lr ilr I lr lr r r g i r,l ' r_ llit.ir l('zil'r.rt .iiikrr a,lirro.tc se g!'tseftc Ia nivelul chiasrnoi uptirr. I r : r r r r IIi' I . I ' r ' r)rrrr(' r' ,r' r.l l tr-ro l c p u p i l a re sl nt pi crdnte nunl ai Ii ! sl i r)l I .:rrr Irrr 'r I r . r r r ir , ' I ir r r ' |' r r' ,' rr' I' ' . i , i l c o s l ,oc d rru ti i , lY cm o heni :l nopsi e i rs{)oi l rti i rtr ,'r ltttli ii ltttpiltrl h urt..iurt oltsice (rtrxti-,ia hcmialopsicir, :t_ llti 1,Vll trrr'l , l | ,r' :,r i rrrri Irr ccrrl llr.lo trlo o lr,rralirie yr,pil u,rd, in. ^clilsrnei 11roduc ,,rtttrtrl, ri ,rtlr hil(tt)?oftr,lc, i.' i,ianp co lezirlrLilelatcrale ilr'chilsrrL.i lttttrt rt lt,rttli ir 1ru,yt.i.l,a.rd, i.n, aimpurilc uizualc hinaxtl e. l: ) l'rtltli ii prtltilu,re Jd,rci tt,tlblh,dri tle uetlare, ca, Llrmitt.c ir rrrr()r. l i .| |Il ,r l, i l|r r i. r , lr l o Iu p i Iu c , rc l s p c c ti v d rrp l i ce so pl ,oduce i fus1}i ri ;i | r,r, l rr olr ir r , r ' r lr r r , ir l trl r. t { ,I:l c x u l l l i p u l j l a ,r. :t) l',rnli:.itt. i:t;kr.l.,il rellr.t uLui .lolomolor (pupila tL: tip Ar.l.t4| lirr . I'r'r'r ,r r I r , ' rrrrrrr i. I r':ri,r' i (ri r' ri o ]rri r : r;r,.fl c x i r.1 t' rl i l ,i rf rr hrrri rri i (rr,ti i' rIi rr' ,,ri r rl r r , , , r r ; I . r r I I r r I rIIil ). )i s l ,ll l j l o fl ,rc a C l ,i e i p u p i l U c pol tt;r,u1,(,(l .r)l ,ot :)l )l ,ol ri l l i r, ,r l )i r l' i' r . il t r . r r il, r rl ;i iv i z i u L l c ,,\Ii o z i .r, (o u rti ,s p uns foar.1,r,: sl l rl r l l r, l i ' n' ri .r I r,rt i, r ilr iz t ) ( x ll iit sj l l l , l i (fl tl n oc l i n i c o o i tr0 :tc o rnpani l l zi i i tl tl ol r,l tc i trr,l tl i rrl ri l r r,'r,l ri. r l, : r l: r ,lr r r ir r : r.rr,p u p i l l l o 1 1u t1 g c l 1l jrs o l i a l,i i -qigrr fl .cl ,i i l nrrri l l t 1rtr1ri l 1| rr., i i ,ttl r,' t t t r l lnt t ll l trl u rl " tttt i trs ,{ .;1 . ? i -.-1 00i )1, rIi ' r .i rzrrr.i l . i l ,i si l .i l i ,r tt, tr.r ir t r s lr r . r . ir r l rrl rc s s i i rrci ;rrr' :rl i z i c g trrrc l l l i Ini g1l qsi 1,;1.' l rr sl ,rr,rl i i L, r ' ' . llr \ , lr l.l: r lr rrrri rr:r l 'r' l i k rrrl 5 i i rrIIo r rr1I| r,I. l )rr r,,l l rrl rl ri rrrrrl l l rrri , l rrrrrl ,o 'rl ,r , r z , , l: r l: i : r 1 1 .l l r \l l l l ti l i l l Q rr)l rl 0 r 0 s l ,| l r i l l tl ,rrr;tl i i . l r:r':rl r / r ir l .l rrrr rl | l | r,i r.,,;rzrtti ,l l t,i rl|l. t i|t ||A |r lt ' ll I i rI I rr,r' I IIrI rr rI rri IIr I r,r.Ir| . i rr tr| r,sl ri l ,rIr{ i i , i rrrtrr i j | ri l l | | tu. l , rrrr or , lr ir t l : r lr . ri: r l rrrr o l ,(rr)(fl r ri l i rl )l l tfi rl i l c r l , l l l rrrrri ri :i ,i rr;rtr| ,i Ii rI,| | | | sIII 't It

.) tl) t t i t)tu.t. l, lll itoti t tlt ttn lttl,,r ,,tl,t :t |) tttrrz]t lr p l.,r r lr r r lr ,r L r lr !ll,L lj.lt!: (.,.1r. | r r : r lr ' l r r.r,l l i l rfrt ul tl i tl trtl tl . rl, rllir i o ! r t l r ) ( l l l ( f l l ( . S i l i ( . Il l | | l t \, r .,.1 :tlr \, r l r, ,. .. l ||l l ri kl i i (l t i I I i ( I I I r I i I ti ,l l l tS

, , , r r . , t r l t t : r I l l ri l r .. l)jr(r lr rr r l r r r r r tl r 'r r zr ,r r 'l ttttl r r r tttr l o :t, t;r r l r ttr r l ttl , l r l r l r " . l , r ' l r t r .z, tr i ,r tt l ttr r l r ,, ,,1 , o r r l ( r t r tr l tl l r .Ir ':r Ir IL tti . i i l tt{: r l l r r r r 'fr tr r r , | , : r r 'r 'l r r r i r rf i l tr r r {,i r ', r tr 1 r r tl r l r r L :r . l ,r r Ir l i l r ':i :l r tr r r tl fr ]i ,i ci t,;tl i tttttl l ttr ':t r r l r tr tl tti r , r 'l r r l t t t t l r t o tl ttr r r r .o ttl l r r r ( t,. l r r t,r t ,, l r ttl r i !r t, i tr l i r r r l r r u ' i I It i tt i t tItt l I r o r 'l tr tt , r r r l r t r : i l o s il 1 ( l l l ( f( , ( ,( |||i l i l ( r tIr r :r n r l r r 'Ir t l ttt;ti l r '. l , , r r r r t l k 'z i tttti i i tt l i i tr tl to tr r ttI r \r 'g \'l J Ii o l r t'tl so tl r l ,r l l i l l l l i i sl i l i r r r o r r l t0 , , . : r i . i i c r l i u l ( i {'l m a i p l i [u zi l 'i l :r l l r .zi ttti i i se r l l l i l a tti l t']ttl r i i i l o t tttl z, ttl r ' J , , ' i r l {' r ( 'l l cxu l u i fo to u r o to l ', ( i l t ( L ( r ) scb i l e l l r r i vcItr ] ( xr l r ti i i l l t i i Ir ) r l cr i o r r r l ' r : r l s t t l r s l , rL tL l j o ico n n $ i i p o r i l ) {) d u cti ,l c, C i tl ti r , ttto {i tti 0 i t to l l r r r ttl r r i r l r ' , r rr o t l l i t c - r o rr yo i g o n ,l i , se g i sa ,l te m a i vcn tr n l fi csti o r 'csp tct'r l i i . Il i r ) z:r , '' r , , i , \ 1 'r r 1 i r r l i l rl i l i i , fi b r o l o r l tL l p i |r - tl i l r tl 'i tl l ,:r tr ', e ste l r o d u si n d c a ti l ) g e l e l

r', r,obolitrtl de la regiunea tuberiand, trece in fatra corrjstu'ii l)osl,r'r'iorrrl'. f icr(lor{rir singulari, a reflexului lotomotor (sindrr.,n 'ltrllll litfurlst,tt i,/r, l so porutc intilni in: tumori mezencefalictr, cn(rcti[lii,i' lrrl'rttgir,ri, ,lLrlx,l za,ltultt, poU oencefaliti , sclerozi, mtltiplir,, a,lconli$nr, zrrttrl zrrrrl'r,t, r r.llrll,i,islno Oranio-ccrebrale, In acuste cilzuri fr.rlorlr(.ltl,r sirrl trrrilrrll .r1,.. Iiiril, rniozli, li?i,rica pupJla si, fie cxcentlici, fi ru)rcgltl:r1ri,i:rt r',islrLtrr rl lr liolnNl,i'opini:i )ste evident ;i rapicl. I l)'lttt [bu, r iir iLe r eJlelx *lui. [,a'intuneric liclilextrl pupilo-tlilatator la intuleric este Inult rnrli vttlttcrrrlril itr ,,,rr' l i ti i pel ol o gice c: , rccl , pupilo- const r ict or I a lunf nil. - t \ t nbulosit t l r r lr olil. ,rr l .zi trl ri l t: ciilor com ule f izuale $i pupilar e, insl pot t i ir ] t t r '{r r Jr r lr '( lilr 'r 'r l I l,.ziurLilc de trunchi cor,cbr: . pulilar'ri a lrlrui ochi osto ([ i I r] i r I rIi t I l L iiiur lrr oazril in cale ac1,ivit2r1n'.1, ,1,(,lirii, r'efiexul consensual la intuneric, pro\.onit rlu lit cclilrt'll, ollrr, l ' ,,l l l r' (l onri ria r c&t ivit at ea p1t ] r ilar : ii ( sem nt t l lni ) I ar cus ( it r nr ) . lt : t r t ,, lrrrl slir iitos este stimulat qi cdiilalt este it,oop(x'i1,pttlilrt, rir'tttrtIo:r:i:r , ,,orLI,r'r,iri,ri nolinal. DacA se ilumineazi, oohiul zrfocl,rt1,;i ccliil:rll, r'rlr, ,,,1,r' ri l i , i o ( 1illli1lr '1r st lt pt it r zr r al l i {r c nr m ai o r er , ct ie m inim alil, , 11t r ] Lii, tde ,, r, r'. Airr.sl semrl a fost doscris in neuitele t'ctrobu.l,lrur?. '1.'t llll tlln r,rd,r il.e rel'l,eltnllLi. de a,ptt'opierc (tlc ul:trnndlrc ) .\llolilL';L jzolllt:i l pupilooonstrioliei ll ltlivitt'tt aprtltltrr /sirr/torrr rti itt lnttll IJri*:r'!totL itn:r:rsu.l, ) a fos1, tiesorisii ilI olt(xfllirliirl,(,1)i([('ttri(jai r' rrrrrlisr )t|r (ilt,]iio]l{r clt intelesat'o1l ol'bitci. NV) lrlrrrliri Tnrpil.uri:lon,icc ;,i trrl rr;i r ; r t lpupilci lr olr icr :colt sLi in: t lit lt 'illziL, t clilt >. lit Lt t nur lot sllt b, ," l r' :rc{ j i i l )lli) iluil, kt r t ii, it r 1; it ir pt t l r t t llr ixt t lt t i llo lt pt r t lt it r lr ; ii lt t llr t t t 'r ir i
! | rr'()Il |()(Ii IJ r' .

r t ) ( t t t r , r o{io it t lt t ;l r i (l (,s( . r 'is lni. liyr u, r i t lc t r t ] r t i0 Tt r t , lt ilu. rttot i r . i. oit : rrri l rr, l rrrr r ir r ir ( si't t t lr ot t t l ll t sNTt ln, tP'it , - t r ) ; lr ) r r t t car {io lt r lilzillir lr r , ,,,r, r' !r' rl r ( sindr t ut r l Nur , n. gt r ') qi t r ) int it zit lclt , sr t , t t it hr lit t lt t lir r , Lit , iI r i( r r ,l I trl l rl !r)i rr i, cii, r yi lr r ,r , ot t vr , r 'i; ll1, ii ( r int lr t t wt t , l,l. t t i,; lr l, ir : su, t .ttr,l lr t i ll r ill il r i ,,r ,1.i 1r. qr: r lcr li colc llc! l, ipt r r i r kr pt t lr ilc 1, ot r ir , tr:t 'plt 'zit t l'ii nuir r l, ,, ' l , rrrsi I rrI I rrrr': 'i l i , it r t r lr , t t t r ul r t t t Lr lt i, r rlisDt t liut jlr r pt t I illt r ' r jt t l t lt t r t i rr:,1. ri rrl l r ir r r lilr ', I ic ir r r 1r I lt t t t r ', lic r , i( 'lJlu'lli. tt , s; r t 'ol, t t l ,\i nl t,,,ttt t l lui lt lir : ( sr t r . t r l lt r i ll t it . l. / , lrils ) r 't r I r lir r r I r r;,r r lit t ; , ; rr rl i prrl ri l ;i l o r r ilir , 1i t I it r r it r t t r r t lr r , ' , r lr x'ln't t r lit r lili( , . sir t t ir , l'r r lil( : r t r , llr r r r , lr r r ( l ' rrIrl :r l rrrri r. : rr lit t lt ilt lt r r t t t t t l Ar lil cir lc t t t r xlr , t r t l r lillt , llr l: i, ,r t , |lt t 'r 'I t lt vt 't t l, rrrrrIr: I r' r'rrI {s( t "i, r lir r |r r zt l| i) . liclr f ( ir r , 1r u I illr t 'ii l: t lt t r t irr :i t lit |r l: j lji r xr r r lr , t t

't't

ru rl :r r . il r r lr r ?ir ll, l (.trl l rl rl r , rl r l :r o l l ri rrl :rl i .r,l :ri l i l i )tl ti tl l l :t rl r' l rL :rtt: r lol.( loI r s I t ir r (i :r l r g rrl :rr:rl r , , | | | \ r' I I ' (.| | | i I l )0:l i c Ii :tl l N i ' rIl l l tl l l t l i )l ttl l . trrrrl l r r r i|lz ilr lii, S ir rrl to rrrrrl \rl r .r l ,rrl ,l < ' rl r,r.i s i ri l l l | s l i r l l ' | | ' l i tr rl r.r:rrl l r. trl rr i l l i :r \ 1lr lr . r |( (I(,I{' I t r: I i I r| | | I I 1 i ' r' r l :r rrrro c l r i si l t l l oi l l r (,{ .l ti l i l l i . l ,r' zi rrri l r, r|rl )r)Dr r ill) ilr f l, ( ' |l|u s j l t(l r()n rrrl \rl rr' l ro l Ii s ituttl ( i rr: si si t' rrrrrlri l nl )rl i {, Iti l ro l : ilr r r r r r s , ( 1( t le \i l u ti l (' l ri l ro l l rl rrrrro D rc z c l rcefal i co, I,{' gi uri (' l t Ii t(,h (rl l l i t, ,,:rrrriI iot r r r (I, iliir r . . l)u D i i ,H Iu ti ]l :l l l s i (i u rl a l d (19ti 8) k' zi uni l r, gl l rgl i r)ri ul tu ,rl ri rr r iI ir iji) lc s r ] ! i d e l e z i u n j i rr g i rrrg l i o n i i s p i tal j , fapl i rral c l rI r,xpl i Irr fr : rr.l l r . r . i: rI r si. ( r { ) ci na l i n o a F J .i iu rtisl.trtfia i)tltsc,ulat'd ntiotolticd, (boala lui Steinolt) lr [os1, (k'N('ri$rl urr'(,ri {) l)upili mjotir:li cu contraclie lelt5, Ei slabi,la lumini fi cotrl'('r.g-cr r1ii . lt) ll,i.?,pltsul 'lLtpiiar ciJnsti'l inttlo serie de tniscriri allcrnllnl;r, r,rrlrirlr, rll' r,rrrl|rrol,ie {i dc dil:r.1atiopupilar.c clonice Si ritmice, amlli, |Ji d{'stnil rl',, r{ r'lrlirl0, cNre intol'cseazil irisul atit in lepaus, cit mai alos la ,,lrrovocln clr," rrrirrr,rrliIrrr' l)Lrpilare (de piltli,, cn ocdzia eJplorirjl reflernlui fotornolor.). \{,('ri Ji'roul'Il p{)lrio e\ista irr sta{e ,,frnstii" qi lil unii subiecti ltorlrrit,li, rl :rr' .r. r r J r s lt ' r ' i ir r t l e o s e l tii n : a ) p a l a l i z i i l e o cul omotorri l ui corrun ]l {i cl l (. ri l rr,r lr ' r ' s ilr nr , ) c o l e c , l 1 re s ,s c l c ro z i i i n l l i c i (oa un fel al e ,,ni stl gnuN 11r prrrlrilrrr'") (liis(!', l9ll2) ; c) miastenil gr.r,\-is; d) rl1]eori f:il.ii valoale scnrir) l .r' i l ri r lc lit r iir i ( 1lis tr,, 1 l )i ? ).

| )l trrl ' tt \l ri rl ri rl (l l )l r' 1r' rr l l l ' r1l l r rL rl ,rrrrl r l ,' l i 1 rl l r' l l ol r:l l l 'l' Ittl I1IrrrIIItotrttI l l tl tr' r It|rrl rtl tl 1r" rl r i tl ,tt i tt't l l r, li l (1i l t l l i i l rrI l r Irrr ' ttt Ittrl |rrIr' |rt l rt r l l r i l l tt l l l l : l I r ,r'l : ' :rl | {r||I|II( .|I|tI| o1o.r ' Ll rrtl r ' ttrr' ttt;tl l t ( r )I l 1 t I l l l l t r r i l t t l t t r t l' rl Ll /' l l l ri i rl rrr.l :l l ri t ' , r,rtl :rl rrt i ||I(),|l |I |Ii I l l t trrl r' l rrl :r1"

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( lot t t 'yt 'r 'sir t r tI, ir t t Iri rt / r ' sr ' 'lt . ir , ,,I. , ,, , ti , ,, , ,, ,, i i i r t r '( r . r 'i, r - v, 'r r , r r r$. ,rr ' . )i ( i) . . .r , t igllr t it t lt l' r lr ' lt ' rx) t lll) l'{lsillllil( t f t t t t t ot t llt r 't 'clliizclt ziit t lt t lllr : ii , ,1, ( lir r ' l ri r,ci , l": 't r 't t 'lt t 't l'r 1lir t ( '\ islli sr r , t liiii iir f ar '( ' t lllolo lt lLuoli ' 1, ,' .trtttl rtt, '), 1' ;. r cr r Hliu{"r r ! - r r ir r t {i( }lr r t r (l) r L( 'uLir r ur lur . , , yiir 'i, "', ""i0, ,,;;,;;;;;; ) ,' | i i ' ,,i, , , , i I ! r xlr 'r 'lr lr "l' ; O l) r cst ill'. lll71) ( Ar seni ;i ' ' rrIr' rr trcvtl tl g ii ( l{1 lr ip plu}r it ir ' 1. . l1) 'il; , ir ir r . l cer ld; r li. r ar ier iosci. r ozir 1,,(;t,)-/t ) /l l ti lit ( lof ! , : a1{r lo- - , si .( rtrr'l'rr 1,,,1 r r' (tl i rl rt' l , ir k, , , blism 1 ; llncf u boli inf r : c! 'iolr c ^( glipi '. si ( ) lr r ( 'r r r : r r ' t t t er , 1', 's"l, '. , , r t ir nult iplir ' t 'nt x: f it lilt r ( At soui , ' :," ' , f i ' | i ," f," ]r 'r . 'i, ll) {ii) . t' r,i i i I| )(Lr' (!lr t n'lr ) trillemittalti secuntf,ard'( sittTtkttnulir:d' :'.ti./.:!. N (:1't'rllgiu ( [ lt l) ii' t r t t r t r sr r ; 1 ir ', ,l silli, t lnclilTL' s', c Lr isr lniliill( ' { t,i ui l ot('l( ,t Lt r r - r 'lilgici t ''it lr ( I c lil' lr t r \ l ,r' r,,l r,' i ,ri ,i tl , r ct , lc lilt , nt 'r 'lr igi''i , , 1r ir ni1ile", r lt lt ''r cr t t I t lt lt o i f t t lt t Lt t l ,l i l pi rr,\i \l ,i oai, olt llllll ll( ; s coir t inr i', con^st iuf il', 1xr t t r r vt r r l'1i: r it l t 'a' scur l'c r oYr ||] gico *" p, , a, , iir t u" r' rr(' l rt' gt' r r f it I llt L I - f ie" s im pr tl'it 'l{icc lir lt 'r ' ' ,,,,,,,i fi " 1" ] in ct t ' t I it uzc pr r dur it liit r l ir r 1i ([(f 'llgiilo la' f cnt nnclt t t l 1i r,1' . i tt si atlii t nr t i il, vr lllslll( ' ir $isiin( 11t - so "ir t r ( 'r {t it r . ) . 'l'o tlltlll,ttrltl so stll l)uin(l serltltc obi{fctivo: .ltiprttrll'r'zlt" :tltrtt , | | r| , .r'r ,i rsr ai, ' t t ivr r lLr l ln I it r lir r r t r t l , i ," .i ,, rrr.rr lr u iuir , i, t ,r u, , , lt t t ilt , dc sot lsil) i1it i! 1, i', i r r . r I ' vlr lr r i lr r t r r r r r r l : n r r , : t l t l : r t t t i'1t t t r '' lolxr gr : r l'i: ' ;1,' ; ,],1'f , , , t ,' , ' '. r lI I 'r 'r r \ ", t r 's{'lllJir lr r r 'iit ( t l! r 'l|, n \ l l l i sr r elit ili t l'illr lxt t lr t i c rrtl | ri . l) l( r l( t ( 1( " ' ;' ,;;' i i ,,' ;;,:j " ,:rr t 'l't 'lr ' r r 1': r . r r lizir ' 1i f iiuii . t i. , t ut n ; i r '. r r t r lcinr L 'r 'r t ut ir ' : , 11, 'l . i : r l' , r l'i, . r i. l. 'zir r r r i r l, , . lr r . . ir . . \ , . r . : , , , . iir zr i , . trr ,,, ,..| ,i i ,,,,,,., i, 1, , i, ,i, / r 'r r ' t t t "lr r ui' {ir "t r t t 1r r r t . z'' t " . . ' i. il''' ; 'l|; , ; 'i i'lt '' ;: ;,; ' ' ' : ' rr ,' :t Lr,;l ll'' l( t a I ) ' I r,.r r'r czi t' 1x, I t ilt nkr t t t 'pt ll( x) l) t tlr-lir ( r f ii'r lt cllzi sl) f o l) ar ?: dl(tlJu: ! it t t t i t jt t ii't \ ! t st ) r t t lt l t t t l l \l rl l (' \l rl l r 'lit Lir r l ' l ' ,,,ttl l ttr' : ' 'l it xt 'r d'iJ{)l) ill1r ( lii r lt r t t lr li t t t t l'r l 1' ''l ' ,ttt,, ' r il, t lt lo: t ii t t t 'r t lt t r t liiTt r t slr t t lt l iilt r 't 'r I t t t t r I : r I 1't 'igt 't r t it t : t Lr t r t r vlir lgiilor I , ' ,, ,, i t I, , i i , ,, , , , t I r r I iir t , ir lclr lci ll) ?1) ): , \r rr.tri rri ()1 , 11'"( - r l, Ll r t lr it r ci lt r t t t t qlt it t l I . , t t lo ' .tl ' l ' trtttrtilt t lt ir lt t 't nr t ilt ; 1' l111r 1t lizt 'r trzli t ( lo: lr , it lr llt llt t r t t ir t ) i, llt ot lt t oi; t t l r lr llllii f t '( lllr ' ,, rr' l rr.l rrsrr,tt, t t t t l, 'git lt t t 'lt . q lt 'l l ilt ll{ r . t llic|i ill ( 1ll t lr , l( ) ( f illizllt '( r , , ,, , , ,r , ,, , ,, i l ( lll'vl, |lci( , 1r 'ig|t nit r r r li, r 'it t r lit r l lr t ir r t t t t t t t t r r t t ( ) 1r r cst lt , s1lll. ill. i( 11) 71) ) ( '\ iit r r i si ,,,,' i ,i f,i tI,' t,,L, , , f ( ) l) 11't 1( 'll' l1i'il) ) ' , rLrrIrr| r' (()Ii r |i t r t t t I t , l1) 11|,( lilr r l' t lr r '\ t st "t r i f i rll
lllI l 1 t'ttl tr ^ l tzl i tttr vt'l r l l :- i i l t i r l t'l l l i l l l l l t' r ttttsl i tt l t 't \ | t t t i t t t) t||tt( I'( ' t i I r t I i I I tI (' I0 t <l c i vr r Ir l ti ctr l Ir r IIr r r l i i Ii ' ,r 'r l : r l , I r )I ( I i ' i I t I I I i I r 'tl Ir r t1 r o ]IIr tr Ir ' ttt 1 l 'l l i o tl '\'l 1 l ( i :l ' i ttr r i tttl r i i .,r t tr l r ( {) l lrt ,;, ', , i ', , , , 1 , i r , I r r r i l ,r ( :i 'i Isi l r r l Ir 'r r l i i ,( l i l r r l l o tr l t'r l ttl tl ttl r l t ( l ( r ( t tttl ti l i tzi tt, o l ti cr l l l l i tl l , , r l . 'l r l r ' , \ r ', r l rr i i i i ) 1 ,1 ,'sr ',r , , l r l r r ', r 1 . . | ] i I l ( | I Il ||l |||'l Il |],.||l l |l It|1 ( |r 'r 't'r .l tl 'Ir r tl ( |,||I) t'l '( 1 1 'Itl i l r l It|( l t'l ti l r tl l l r r ttr r .l r r t , , r r 'l r t l o r l I I I i I rr Ii Ir t'r ') l l l r r xr l l :L l l i tl r l ' I:t | ( t i | |t I t t t l "l tl i zr 'l tzl t' l l l ' i l r k'l l tr 'l l ( 'i l t l l l r l l r \ , l l t t t t t ttl t,,tr ttr r 'tr ' l r .l 'x'r | | 1 , . , , tr r r r r 'l r |l .,r r 'r ';tli l r ttl l r t' 1 1 tr l l r ,t ttl l l l l l r l t\ l ,l zl l t l l l l a ,l l l , r l r r : r I r r I I r I r : r r ,t.\ i l ( ,r .

l 1)?l ) ); l )l ( ' rt t t t 1t t t : ; t t r t t i t ts ' t.tl tttt (rl ttc V ti s l ttr' rl l r' l l r' { r' i ti l rrtz i l rttr' ' l l Ll i l I r:r' tt' l tr' l 0l ts rr s l l l )t t i i )i l r' (' ' l (s tl { ' (' l i \ i l l (' l l l l l ' l !' l rtt l l l l l ,i l l i l l i i

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:rl . | l l , lI r lr ' |||i||: r Lr r :1 1 1 ,1 i 1,1 | .I 1 1 1 I1 ," rI ti D c i c ri te rii : :r) si nl t l l al ' oxi sti ce; l l ) rrrt I,r. r , r . r r I r iI r ' i ( i) ri rl l l i l rtc l a l o I 1 1 )s i n t Fri ri ct l ocal i zi i tc i n teri tor.i rrl trr,'r'rr rr r : r l: r . ) r I r . i i ri i ri s o i i to d a s t' ri rn ed e s u f(l ,i rrt1iorgaui c:i (tl i n parl l ' rr Irr,'r.r, r r r r r r lr r r i r r iill l ti u l s r.rL z i t,i r., d i i r p a rte a a l i tor ncn' i cl .:i ni eni sai l l l l l ,,r r lr ' r , . lr r i r r r , r r l o l r' rq i c c ). I)u t)i i ,{ 1 s e r} i [i O ]j rescu (19i !]), tl rrcl cr fi i r,rl ,,'rr rrlr ' , . r i: rr ' r r il s jt rl rl r)l l l i u l t c ti o b o a J i ,,i tn 1xl t1,csi i exi sl e o ,ti )fi ti i l i i l , , l . u rlr ! . l, r rr r r r r. . | i l rri l i -ri " (D ri rrl rr.i ,)[i (i ..a , rj i tn])1a]r]tal i cl ' J l L ncnl tl gi ci rrr,,.r ir r ; r lr . iir : r . r ' r ' rl i l r.l rz ri i ,s l l i ' l i d c ta c i i ,,r -,$tc i uta, si Lt{ ,{ ,i t,si }} (} i l l l ' i tt, l rr rl i l ,,r r , r r lr r lii ir r lir l rru l :r;rr z ;i s i r,,p l i rl i i i r.i rr),1i :r,ti ,or.i cii ol ogi ,.J i i i Lnttrrrrir rr, l , l r ir ior i, r r 1i< , c s irl rrra i p rri .h o l i l l l ' n tc , n a i grc,Lrdtrccl al ri Lrsj (l { r l rl l l l r, ,,rr rl rnlr ' iir r , ( ' \ r ' s c t r i s i (rl x ' c s (fu , l 9 i f)). l r l; r i: ur i' i t r c tr' :tl q i i l ,r' i 1 ]c 1 n i n a lr1 0 o l r,l ul i i ,,l ri tJi i ti \rfi " , 1t1,1)Ll i si 1'l rr. rr lrlrlr, rllt r tntlqnisnt,l, putorrcnic ii,cl,iotx'azi ll, tt.i,lt'[, t:ottltttI lt'.1,r'l rl , \ Ii l \r' ll) s : r r r i; r r lc o s r' l ri l a , rti t:c ' i , p e rti ;fd i c (c-r1,r' i l rrct l l rri rd). l ,l r lr ' por ilr il ir r s l rrrl i rrl l r,tl rri , l l t,i rr rn i .j J o itci r l rol fcci i ornl rr rl r^i rri r,sl i lr(rr', rlir s { . ( f li( l( ' lli( . 2 (f o s r,t' i i ' < l r' ./i rrl .rr? tl:,s l x )l sl l ri l i rl .r' IrI' orIrrrrcIr,Ir l rrol rl r, s i rl rl rs o IrrrrIr,rrrIrI(' si tl t, l i ' nrrrnr.rrcrl f l rrrl i , l)rtxu |(f r lt f t lr . t t r ir ' lit ti z trl r,, lrrl rrri :r lr r i rri r.l ; t \ r)rri t l i i j l l i l i \:{ ,ttr i l r' rl rl (.l tl c rrl i l rr,i rrrrrl rti rrr.rrrr rrr i Ii rl r' rrri l rrI f r' : | | | |, I rr| | rt | | lt r i { lr r l l r' . r' trrrrrrl i l c i IIII| .| ,Ir., Iri rl ti rri l l t, l rl rrzi l i r,rrl ,\r,r' rrl r 'i tl

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(.r l|| lll7 l|t) ||r'\ r . it l. , || I I r, I ,. rr r rI r r |, , r r r r r lr , lIll(,r)rr ]ii,ll, llilrr(1o (Ali r.ltl ,1rI ll|lr.ti( |l, l!l/ll). '! ) 'l'tttttttilt: t lr (.t ,t | )t t t t I t t | : . lux t t r . , t , Lt , t l, t r t t l, , r , it r l i ( l r l ) l : t i ,l ,. ,\, t,tlilIt,tI t lt ( x t . lt t r . t r t nr , t r t tt lr ) A q , n , q l . i . o t t t r l t tl.rit i . ( i t . , i , . r , : i i , , ; , r t t , tt[,. t tttltt, n n, lt,,ttt r ; 1. , t : t ir , , . |, . , . t r \ r l. . 1, , 1, , i r r r r r , . ] r l t , t l i . , r . i , r l i r . r , : l . i r l r l , . J , . t . rrilr:r r,rr |r'||lr'\l ( ' l Llr j t k , r i||ir l ( lf lr ilr oc s l. r : z i e l , t , i ( r , l r r i r r a l i j , si rl0 ptrrr.ztr rr i' i.rrr rrr.rrrrl.rri ntot or ' , . dul( ' lil. liir r L ll[ ir r ce p u t I o , L ] i z l , t . r](, (l slrgrr.rl r'llrullr it 1r'ig-crI1elului,. apoi ill l)r(xl progresiv extinzitulrl sr, p0 iLrl|r,ri

l , : r t r 'r r I I i r , t I r l r | | l| ( ( 1, l l l |r frl !( ' [ , l l n i l r ) ; r l ) l l tttr r ttt I I t t ' I I t II I : r I i I ' ( ; r ') 1 L ( l l r l l , r r r r r r r r r : t I r , | | r | | | |r ||1'r L l I r , r 'Ittr r r i tIttItti ( ,\r sl tr i r ;i r o l l r l r - , l l ) , 1) ; l ) l t rr t t t r t r i rr; t rt ' sr r '{r l r r l r ., l l l ( ;1 1 ) , r r | , r 'u r I r r r u , r 'r ':r r l r . l i sl r tl r r t,r ttr r l i tl o ( i i L r l l l l o i l fi {' ( l i o :t'r ' l t) tr tctr i tr l l i l r ' l r :r z:tl , tr r l ttr r r t"r l ' ''I I , r '. t r r I r o i | r '| r i It r r l r si ttttsr l l tti ( i I\( fl 'l l o i r I r l i {i r , c ; i ) I r ol i r l ti si sl ,tr n ( l r o l l l t, l u i l i r r l l l cr ') . r r tt r r tr l r r r r l r .i i l a l o l cl sl .l Il L tr ., N fl o ci tr ,zi o l tl i l tl l r to p l cl i l i ) ,\iitttlronul 1 | r r . r i r r r l i i d e a ce e a q i p a tte . l tstl tr i r l tr r r l tl l r ( r i 1 r ( 'vl r l l r l i l ti l f r r r r . \ ) B i . t d r o m u l [tti . Gr a d e n i g o i tr l l i ci

t) 'l'tt.tl,orile ntaligne nazo-faringiene (ittd.eoscbi carcinoilme si srrl r'rr:rrrrr.)irrr':rrlt'u zi\ b:.z^ crnni]4ui fi afcctcaz;i trjgcmlmtl in Z0;;, (litl (,ir,1ru i ( \r',\('ri ;i. (\trcscu, 1979),,fic prin forarnerr oralc, fie prin {oi.,irncrr lr.r,r',r.'1 f i. crti'zinth-se prin f-osa ptc'igo;narilari ;i/ sau prin sirrrrs'l rrli rr,irlrrJ. Lir trov. gia t'igeminalii sc asociazi, semne neu'oloiice, I.csJ,r\l Iu rrr,rrrr.r-olltlhnologice, ia ltrtr_cfiede top,rgrxfia invaziei tu]loialc.(l) ( I ll niolt ringioamek:, adenolmelc hipolizule, cu ext{,nsie sulrt,rl , rr.l rr': i, lr r r ( D' ilr f lt a ra s e l a re (me n i n g i o a mc ,S.;.), chi al , ql i oamel e rl e nri r.l r.i lr:rz;rli si tr.rrrlrltlo cu diverse loc_rlizijli pot ger)er"nnei-ralgii trigcrnirr;rJr,, rrr r,or r llr lc c linic c a d e s e a re v c l a to l l o (.\rseni si Opreseu, 1d?g). t) l.l.rtr r st.ntcleba:ule, in sinrLsul crre.rnor qi rn qaigtioni! hri {irrsslr, . r' tliy,t:tz,:.i, rlc olrirrci siurlroamc, ,.om1llexe, cu alinge;e;Di a tltor ncl,\ | , r':rr,jlt r i, t ' r I ' { r . , l' i i l r" l l l tl t9 to ti l o f. ii ) I'nn:t's. tt,n,.r.c.tlc ale felei, nle ca.ritii!,ilor orbi.t,te $i (xle sintsrtilor ,ntt.itll)t firrl rrsoI rl,t I0rIrnriicut, prin sennelc locale ii'prjn coafcctlrrr.| rrrl r r r lr r i r r ; r lic li/ srrrrl r o c rtl o n to to ri l o r. |) lit ::itttlttrrtrr.l. ttltt:t trtui i,/i,it,/), {onr:rtut tle tutnori, hematoatno si o l i { ,l tl l rL o p l c g i xu , o c i ti ]te x $i e\ol frl mi a vi n sri , se.s,' , Irrr,r' , , ir I r r r r r r r r I i.rr, .r,..r' l:r . rrr.ri.rrlt,,i.I rigor[)int],Ii; cu iocalizare pe teritorirll ottalrniorrltri. .t ) l, .\i)titt).,t.1t1 tlc,fantti sfr:naid,ald,, a,\\t*ri de drir.elel loc:rlizrlri irr l r rrl ,. r r r r l, , r l- lr r lr r i, ,rrl rri s, c a s o c i * z r o l l r,l m o l tl c gi a exi ;eri r:i si i ni .cr.rLi io.l , ri rrl I rrrrl r r r r ilr il . i r , r r rri th ,j rrz i .l l l c i J l ,.;r,. (c i t.r t rl o Ii ..r, j 052) rr suJtl i rri rrl p rr,r ',, r i. r t , : r . i r ' , , ,,r i ,.i : 1 r,.\ i i .rl q ;i c i n tc ri l o ri ul oftl l mi c' l i ri i rr :.i i tri .rrrrrrrl rrr i l .r , lr i ir r . , ' r ' : l) rl ,' rl ' ri ," s l l ' o i c -l a .l i l ,i n c a r,c 1a tl ebr* t l l 11i , (,sto | )rl ,l i r',ri I I i c ta l i , a p o i e x ti n zi i tdl _S e l l 11i l ci ul l r" .l i rrrri i .I(,,IIIIII(Ir , l r.0 rrto -p i u L rrrrr : r s i irr rrl o } l i l o c ' -rl a r. ' l l i rn p d 0 ci tcva si i }ti i rrri r:i r!rvr.i rl ,Li i l ' r ' l, ilr r l. .r.l rrr: r r : r s ir r r lr i|r i , 1 i i :i , tl i mi rru rrc a l c fl c x rl u i comcai r si 1l ,i r,r' irrl , l rrri i i l ,r rl , rr, ,rr rrI ri i i i Ir i i ,, pl r' ;l ri l i rrrl t-s r c l o n c rl rrl i,i c ,L, 1i p ,.1,i ,i r1i r;v).. ri J.f rr nitrrlrtyt.tt,l,|(rd(]l,i er.:kirn al sinustt[,ui <:,.t,,n,:t (si.ttrt'totnrriltri .. /",,i .i . / r lr r . r ' r ' iL, l) l\ r i r) t(' r' i 1 { )ri _ u olfta l rn i c rl rr i si l tl rnrrri r;r' rrl rri srrl r' i ,r., rrI I rr I rrrrr; rI r 1I iI I r l' lr r rl r,l z l i p r.i n l (' z i rrn ,,1 1 rry l t,l ri i rr IJ_r,,,xi tl l l rl rrri r,,,sl ,i rrL :rrl : r r r liir r ( l) r ir . { k i l i .,r.i .,]' (' it,i l tc rL l :rL i ov i c rr0 rso) qi str i rrs.l .ri rr rkr rrl r.rrr 1 rrrI1 r lI r lr rs I i r lr : c lr.,rro z i s . N c l trrl c ru g i n tl i I rr,; l r) l rrrcvl i srrrt rrl r, :rrl r,r.r,i ,:r| o l i rlI ir r lr . r , ii, r ' i rrls i rrrrs rrl u i(,i r,\,r,rr)o s i ,l l t,r' rorr,.l l )5i i ; A t,srrrri (,l ri .ol rrl r-, l l l i l ); lr ) l. r r r r r . r ' ir rl . r' r' g i rrri i Iri ;x rIi z rrrr' ,i rrrl .. s.l i i .r' l ,ri r;frf rrgr.i rrr. (ri r,1 1 t't rli r r t llt lr . , ll) lilt)l r) { ,rrrrro Iirrl r,l i g rrI i l ,l (l l:l Zol l r,t i l j l .(,l i , 11r i rr 1 1 1 1I; I I.,,,I lll)

1,,rrr o l ara lizic a per echii : l Yt r - ir '. sr' (rillrlirl('r'izcrtzit pt ttt 9 ) Si.trilntmul ?aratf i,lleminctl td I'tti .Raer.lrtr r ligl't llLi, sit t t I t 'lr t t t l'lr r r t r lr ' l] r 'r ' ,, rrtl ti t i rt 1 eli1, t t lilt l ncnr ului olt alr nic) n YI-ll. r.rri lllnrr paraiizii alc fcrechii $i enoidd,l'ii ul lrt''i''lu''ul t lrtliz' rtz:t l0 ) f i.ndrontn,l tle r,:isplnlie ?eLro-sf t, :ri r rti i nul l ,i plc t 'le ncr r . i cr at r icni: pcl: chilc I l, lI I , lV ; i Y, 1r r 'lr t it r r plr r r r rlr'irrlu-s(. felralgia o{i,ahnicri ii }irratljzia, dc pcnrlrtr l ll. rt ttltttrt o'r'nn 11) ,lnetrism.elc de (|'rterd. bo'zil'arti ;i. ntal,.f ! ii It .trtlt t'i.t) rIt rt i t rI rIr' rI r' 1 l r rlrlsirl.ri dj n fosa cerebrali, po.<tet'ioalri )pot sri rilll,llzczcrt)gii t t' i g r,y, rrrrri ' al gi c,it t sol. it cuneor iSir loheinisliasr t r f r lci: t l( , \ r sct r i; i( ) Pr l's( 1r l, llr ; 1) ) l!) Lea tn,i,leinflarnatorii lot fi l:tlctr)ri (rl,llzirli (l{r ll(rvrrrlsi; irlil, ttl i , rrrri l tti gtm it r l l, r Tif elic, r : il, f i in ce1c0nt lr 'l] ( - '\ lscni f i olt r ( lsr lr r , lllill) l rr si ui i i nul lr t llunint Ll pdiJer it i t r t ni l, im : [ ) Ar t r hw) id"iltlr lr t lt nt titxtrd, (tio tnrghi 1rottlo -ccrcl:cltts \ti jurtapolrtirr(') ; lt) 1'r'tlutoirliltlr 1'.'::it rlrri t,,r rrlr ; <t\ Zrtt,u postcr g8tlcria'tt(i po.'Ltedoclan$il,violt'l(ic ll('vl rllgii l t itl< i. t r t t bit r t 'i r r lr : r r l ,,1r., l rxral i zate indeosr : bi lr t t cr il'oliul llcr vr lui oI 1, aJ) l) i( l) --po 1.mni;t,,llo l)l(roiLl)tr' , , ,lt!iil, lt()rpeticil - bittc outLtisctLtir, Irrr('r)tlr,'t , ,t , r i rl l nl qi po t . er it ot 'iul cilLlt , t r ir tlll n: L. 't ilt luht i i] lll) cli{) r . St r it sr t t r ir t zrr r r lt r r \ : r t 1e m t llt c or i I i li( 'lr liilli' I ll( ] ( r llr lr r iii' l ,Ll rrr.rl rzi t' pc t er il liul r ( r sp( xlt 'iv, \ ' ,i i l o l )ol l )('r 'sisl: I t : ] 'r t no il idclr r t r glr l, i, iur leosir bi llt , blilr 'ilt i. i\ r lI sr . r P, r ; r lr ' ri sl l r o ,,(l i sir si. czio ;,,.r l) ost hetp( ir jci " ( . 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I' rrrr t lr z. r iloI r r iir lr r :' .1;.::.1 !,'t , t li: iilr ' . lt t r ir r lr t t l! t t t lt ( st t llr t t t t t t t l't t t t ) j'r r ! i r l'r r r r l( r 'r ' rrrr(' rtfU l l )r' i t: r r ) I it r r it : r t cr t l, ilt r llizif i iir l, t 'ti{r , r ir ll lr r llil lr r ll|| l; r I ir t lr t lr t i (l trr lt t l r . t lt t , r r i, 'r t li't r lr r t 'r r t t t , l't ir '( lr r t t . zii lr r . ir r lr i) ; r r ) , '\ ir , r r i. t r ': r ' rl r' ,rrrr' ;l rl lllll l( '; ( [ ) l'ilslt t r t r r r lilr , , i l r)r' i )l tr(' zollt , t lt r sir r llt t : lt t l) ir lllt ii( [ lll {i( r il, ( l( : ( 'il'si Ii l 1' r, cl 0| 1r,0J] r i0glilli( , ( ,ir , lli) ( liii( iit il( r ' I l'llt l\ ( ', ijr . nz{) f ilt lr .sr t t t llllr lr t lt l t tit r t lr t r r ilt lil'st r t llit llt lt lr l'il ilollt llll ill t , t t r lilii v, lr rr' , ; r' ) Ihr..t'i t t r : t r sr : t t llt ,,,rr:rl r., rl It:rl l r r r '{, ( lf llioi{it l r llllijclr ilor l) or i( nl1li, lll t lt i; llllt 'olt 't 't t t o{t r r t t : t I I t t rrroi l ot al riilr ill . c{robsclr ii ii. t t t t m t r it lt l invt r t 's: lt ist r lt t t 'lt ' lt r i'1"r 'r 'ii "t r r l r : r 'lr r r,rrl {,, (l l r tl (, i'iir il;r . 0li1it lnal. O 0onlt t zir l cu lozilllli i'lll}lir nllr : lclr 'r ( lxr ocI ziot it l ir r cur 's, l vilI ( l( f ai. ii l) il*r liziilo. I ir . ir , lo | ;rl ' ti i i (:1o , . ir r L 1, ip I lt ll, I : iI ilct r f t i bolt r lr i, r t liur t f lr ll I lllr ( 11i( 'i ( lc r 'llr t.rrrr r,l i ol ogi tr ( it ui, 't or gr lll) ( 'l( 't ' lt llli( llN c( 'iL' c( 'odt r lolt lcar in: l 1) {! 1ll 1' ,l .t' l l ttrst:ttl llr esll] ) ( 'r 'ioilt o t le lclit llt 'r 't r rl'oir lr r I ) ( 'r sisiil' 1,r," i rrl i .ri rl :tt'r 'qi,ur i a1. lr e, in sl, lr r liilt 'llivlllr silt o ( Ll|f ( ' r ll'( 'lllir ( f1 ] ( lit i l) alr lr lizil! supr llllll( , 1( . lr f li) ,rrrrl cl i oj t, rrrIsr , ii] ar , siinilil] ( 11. ,.rrrrri D N l c si ull l) ll ist ot ilr : r l lllllii polt c pl'lf Y{r lli or i( i( ' ( r ) lr lllz't '' llt t tr lt r llr ', t r r ' l ' ;rr' :tl i zi a llet , i: lli lclt t t 'ali, ( llit olil, ii Llziur lii ijbr r lor s Lt pLlt r ( [ ( ] ci, ] f ir t t t sl; oolillr ( lll. par t ialii a 1: t t lil t t lui sr llt r 'lit ] l' r r r r t l. r ,,' r:rr,tt,r' i zr" rr zii, !lltiilrlf trtrlirrltli , rrllrirrIii, jttorvalfl ttc taciatrlt supofiol avilld o l o Llt(iz( r, rIIrI r,r,IrI ii . Astlel, lxtlnavuL po:11,c illor.01iIruritol 1i ltu l)rozi|l l,it lrtgoll,rtlrrtir,, r is, clc li1( Li) asilnclnin, , 'li''I i{'ii ( li''r iDr r ' rrr ri ri sci ti l e a ulji) r nu, 1i( x) , r 'ollor(0 rlllt.{)rnlto, oa'lorrvollllliiiuii Iiilril rnol,ot'ii ,r,i^ tll;tolitil ilti;cEli1:lil,iitr[ilot' rrrr' ,t,i l i ntct' .si. t ii 'f . it 1, i, , ", du'i culn ar n lillt ir t t il' t r ut i sus, st r t 't t t t slr t 'i: ir lr r pirrl,c (xt prr,ralizia,Irr,irirr'li''llrl r11r, tlir rt't.retrali ,1,r,:r,i o h.rniplcgie lr.stii'irl1ii, c.tt'lrtrrl., i'ttttrori (plin 1r:rsoll]zrre srtfori.]c ila,cirllcc.n1r'alc ' rrtrr 1'ra..r,lizii citrr4lir,,'ritl:llo, ltsitlrrrl.irt lr'{"r tt'lt 1i.,.iiilor t, l, irt .u,r'e, prirL ir rt.r't:sit ( ;r(1iontuerlzii,(,u oca,ziil' c\l-)rosiei elnotioni[lo. rii itrlr'rl :.1.6.t.2. t.)ard.ieiile Jnt:ial,a y iJi'rice (frin l''zitiIIi rrrt(1ltriit'(' ( lr ' \ 'r lt lo lopout r r lir it r : ' l .:rl r' l l r" l li {r 'ul'al' dit r l, ut r cl prirt lPniu.lli ttttt:lcure. [r]si'r' r'rrtlr:r rl'' r\) -f'oroli:rri faria!,a peri,fet'i,ce ,rr,,ri r ii' lt t it t r ': t lr r r 'lo r ni l, ttttt,l t: ului iLt r vuhii f icit l ii l) or '1iunolli111r 'r t 1i(ir 1,,i i uri (vl ,!( 1ulilr t , l, um olale' inI lr inat or ii ot c. ) . 1ir iL( {isi, ( 'siir r r r ( it r ( \ r, tIi I' Ii I t t i t I rrI , cr r 't L,l ;,rLi i )(l o ohict i, lir r r r liziei f aei: ile, o lcziut Lt : t ,lilt , soioLilt t lt 1 ( ; i t ! 't r i lozir lir ii ,:t\i r,t' uzi t o lt t 'nLipleplicalli( t 'nii, aalicli opusi, ir r r t r r lizr lr L rrrl r.), l i l oalt - se lt ot a"r oeia qi t ulbur lif i d( ' sor lsil) ili[ 11( ]lx! h( r lrit r i( I l'lll r . <i. i, Jr r z, r r''r t ir r ,;,rrs(j ' i ' l i ,ziur t e: riir ilor scnzil, iYc) ; i, d. t r r 1. lt r lli r r r lr li, ( r r ll' illlt f lt l{' ( jf lt llicnir t t ivt 'r 'st 'lll . ! jlr ( [ r o: ilr x) r 1i ,(l { j l r(' t1 'j or i'c collt ur eaz?i r r rrrrl l ti cl i cl rt 'it 1. tt'it:e pritu Le2iulli iu.;lranuclcnrt l'r' lrrtzrr' ll) !'ant,li:;i'i, Juuialt: p ari,J l :,1,t,rI rrr.r rri o l0ilit t r t lit r ir : r i, ilt r r t r of iziologice lj I ) e I ) l'z: 1, lt t t t lt t r lt r t lr lt r r r {ir r t t t r t 'r 't llr t i I r r {'i: r l' ll, l lczjllllii osl i. ul, lof ) olJr Q I 'i| , 1,, fo Itort ; l, rsllt r / t iiyr r ' lr ili \,' . l (' l )rrl xf lit ll( ( ir t t |it lc sit r i': icr lt t l liiolir niilii ( s|t r l, ir slt t l lt r i S{1lt iI t r r t ") , r gisir : ir r 'lil o 5i r lcI i t or r |t t sl ir ') , ri ( i( lius ( 'iir lr l r,l i rl l | ri ]l cr0lot ir r t t , '1r 'lr r t r ltiililJ) iI r t si lr r lt t t it 'lt t r lt 't r it r r $r t ; l'ot t t t 'l trrrl rrtl s| ttri lr ililii( ii gr r r . lt r livr ', I ) i1'( r 1r l) l rrri i l rrl i rl i (( lr : lr lr cr ', ll) ii'; 'l'r r ir r t lr 'lt r i r , ollt }. , ll) {i'/ ; I 't t llr r , lll?l; I 'l1t 't \ r, r| r ri l ' i rs( lr ! lt ) 3( ) ) l, r 'zir r t r il( .ilr llll, lll( il{'lll1f 1xr l, I i gr t t lr : t lt l lr slli'l llit t l rl r, tl tl lr r ' : r l: r lr r t t r t r ' {'l'r t llr t r lt , ll) ( i{); I 'ollovir r it t 1i I 'r t lr r t t , ll}i'io) : 1,rrrr, '
u l , l ', tti l tr t:r l t:ti r n ttt 1 n r l ,'l r t1 1 tr 'r t t r I t t I i t t t I I t t t tt ' I t r l r ' tl t tr n l l h r l ttttl tt r tn Iu :l o :; ( i r r r l l o l o l ti : r ) 'l 't r t t t pttl , ' i l r r r r l ti ;r l ,i r l r ,) p l ,l , l r Ic|l ;l , l tttttl ) t I r . r | t | r | r Ir ',:II;r l l !l D i l l i l ti l r ', r r I t f i , . r \ l t . [ ] r l i r ', I t I ' ;' |. l 't t ) a t :t

:j-5.:!. llrrnrlizia norvulti. trigemen (paralizia masticatorie) so (iiu,ir(l t rt rrt rr,ii ll jlr dcli:ltil, tnatiilarul.ui inferior sple pantea pn.ftliza,tiii ((rll ,,(:rzrirrl('s(lrirlot'iigtll.ii) in caz de paralizie unilatera,li (nuclealir, silrr ],(;ri lr'r'r,.ir ) l l,r,igcrlorului (prin aclilrrel predominatrtF :_r, rnuschiului ptt:r;iqoi rlrir) (.\1,(,tn (x)ntil,ltla,tetal sini,tos), prin rtrofia mugchilor na,iticirl,r,fi (|r.IrIIlr||irIsi rrLesotcr), plin diminua;reafortei de stringere a, maxil:rr.rrlrrj rrrl,,r ior' ;i ptirr rlirnirLualcasau abolilea refterului maseteuo. Sr.r[:.rlrrrrr;te ur\or'procese inl,rapontine(tumori, tuberculoame, gl)r|tr., , lrrrlrrx'rrlllllil,r, {.1.) sau :nnor lezi'Llnifdd,iculalte ale rd,d[cinii m;tol,ii l, I ti Ir' IrIr'r)|I I rI i (ptocrrseneo{olmatiye sau traumatice bazale) sau tron(rtrtu.tj ' :r1,.r,'r'rrrlrri rrlrrrrlibnlar (trauntatice, tumolale etc,), .patalizia u,niltlt r',r/a;r,rrcrlrrltri lricemcn poate.apdrea Si_incontextul unol suter.inlornll lll'l{ rl(' |r'r'\ i (J'Nlri0i. Paralizia biloterald, a trigemenului se poate rcalizir rr r:r(lr,.l rr1'l' srt{rrinte bulbo-pontine (scleroz:i, laterali1 amiotrofi.ii,, rrlr,rirr, rk. s.lrYoziillbclalii amiotrcficd,, diverseproccseintraner-ut,_r iu,L,) ,irr :rl llrot rrrli,r,irrlc llaz:rlcextinso (tle obicei tumornle).

,Ii I,III)III,I.]I\'II,] I)IJ I)IA(iNOSTIC iN PAIOLO{.I]A NER\TULUI IIACIAL :l.li.l. Irrrost,i1;atil scrniologici .,1j nervullii faciai ulnrireqte : | ) l',t.idt) ti().ur,t(ntn,elorclinice d,eTtare*i sau d,eytarali.zie.faci il, .r, rrtrr I rir. x|rt::tu .faai,all)f in probcle bine ounoscul,eale era,xrc1r l. i t,tttt ,,t rlt' t.t rr,rtt,r'n.rt,l,tr,,i di,ttr.tmit:, ,lsupra cir'ora nu ilsisti,rn irici. I: ) l,)rllt))ut'(ionutdtJ.ir:iril,or ] lnd,{odrelor reJlem (Ilist\,7 t1}i2; ll,lr r r.r'rrr.r., lt)lilt; llrpoyii,ir fi l.,asou,I9g0) : a) rcllext na,zo_lluJpdrll,l ; lr) r, l, rrl .r'Irir,rrIrr'rrIrri rxrhirLhri;o) r'{rflexull,siho-palpd)ral ; rl) rrrrllrrrrrl r'r lrlr, Prrl;x'lrlrrl rrl lrri llcclilurcl. 1 e) roflexr corr]orr,D; I) rr:llc.rrrl rrirzrr. lrrrlrr,rrl; !J r.r"ll{rxui ruu;chiuhristaporlius;h) r,cfloxclo rtc clipil. | ) ltt::lqt't:uttusluljl.i,(lllpi m{ltodelc oxluse r1c rlri irr ,,, .rrlrrirrlrlrr l\r'rrrolorlir.)' (l'{)l)r)vii,ill t,Nsru, l1i,$0). $i
l) ) l 'l ) , l;r ri c rr l lttttl rtl o t
811

'l t.\l(t.t1!.tnli.tvrliri., ' l' t x t , lt t ' lr r l rtt.l i :,i rl u rl i a:r: rr) r:x rrrrri rr i .i l r. rk, r,l .rrl ,r,,rrl i i ' drr.r l i tr lI . I t r , { iiI , r t r ll rl r,l c rrl rrrc r' tr{ i , 1 l r) r.rrrr rrrrl rrrI I,)l \l (i ; r,) rrr]i .Irrr,I1,r,Ir, r lr , llr lr ' t r { lr tr r' 0 ItrIIrr,r' t l t!fl .t,o l l ,.]r,. rt

t|tl

r,:| |1 :r i ' 1i111 -q l i l " :i r l ,Ol j l trl i , l On ,.t.r,i l (,. t ) ,u ; r., r. t ,r, rI I rrrr r,.,,, .,rr.rr r rl. i, 1" r,' .l rlr,lr l ilt ( lr . r,.s , l l | | i r d e fry rfU l r.i i n l ezj U rri l r. l rol ,\ul i l t(.;i tl l I r.r, rtt.tt r'lt I Iil tl I c lrlril uhcranl i si stinca temporaluJu i, l:l semnole di: iI l :r.rrl rr r l r r loc ir r z li tl e o l ti c r.i s i s e n l l to d e .' l e zi une a al tot ncl l r 1l,lrtltiz trl rrr,,trr (\, \'1, \ I I I ) , _l e L .C .R ., i ar i n cazul l )roc{,s(,l ol ln( , ({ rn t s i n ro d i fj c r' l r.ja | | | I(|(. | | r1( |I r. I {. tio spal:iu - scnne. dt hilx,t,telsilne jntlacr.:utjatil; (j) l)i rri ' I i ()rrI i{' I rI (l('vilr(' irrsi rrrrri dil icil irr lari'lc sitnaifii tte ,pe:ratirii Juciut(i ltit,l It rrrtt , t,rr' 1xr1: si :tIr,.i itr trnrle Jornt de distroJie nlus;ularai,,di,prli.ntio:,iti ::t rl t , r ir t s lt , nit , ( lllt , l ,t (,_ \l )l n (,' :l tc n t s rtrp ],i ri de contextul cl i ri i c al l xrl i i rl t l rtt. : t . ll l, it t 1, , l. .trtl ri .l u ri rrt .x i ttu -tcp n ,.,i mnt ,yl 4,,1i Jol i dt qol gti o , .l 1 ,i t,rl n l fi ). S r.n rrr,.l r.r.l j ni r.o.j rrti urrl l l rsC rnl i rr:r ' u t'tl ( " t lt t , t t ; u, t ' , t : ,t1 t1 rtrr l ,:rrr,rr r . r ' 1. lr lc u,tri s i rrrl ro rrt d . tn .j g h i p o n t o_ce.ebcl os. ptl Il ftl i zi a :l l i * , l ,:rz, r r lr r i( ' l rri l u l ' l i i n c l y a l i i d e i ' a c i a l , ra cl re sc asoci azi i tul , brrri n r(' r ' r r gil Ii r(' r' Il I r'r rI r ' ) .1rr'".rrr, si ilfccla.ca $rstului in ceb doud tleimi alteriollrr. rrl ,' l i rrrlr ii. lI llt lr ll{ ' !i i z l i s c a s ri c j a z i i s i h i p o a cuzi o. l,lr rrrl i rrr'i l i lo lrr[io]ogigt' alc lir z,,i (,1,J1iuluj fi alt.porliunji pietroe,sl lr . ,, trl Ii lr , r r r |, r ' lr l 1r .l r.r' i rL ,rrl i rrL i ,l ttrrc { l c r.t.. zi l tnr., di e fl ectrtri sau ri l l ,r, f rrrll(' rlrrIri-r(' r,rr r.rr,1 r'r'is I ir. .,rtrt pror:cse sitttGtela {tce*tn.il:el: tnetringio:rrrr., l r rr"l rl, ) r r , ilr , . lr : r ll l trl i .l .l r.. ()s 1 (,i 1 (, te ml o ra l c, C .:l tl j nOl ntC rtU mi l i cl l i r i ,rr , , lt | | |l., I '( I I( | | I III I I I (' , r e ti ts l ,a z c dt h car' ci troarrrI ' l lol cni te r r r,l l r ' llr , : r liz ; u i { ,| ' Irt.r,r' rrl r., l l )(i l )). l l I ) I t it r t ilI s i l trrrl r' ,i ttl tt: l l o l t0 l i o n u l g e ni r: Iri pi ori qi nea rutrt.tttrr ' , 1 )o tri u n . L x u .1 )1 ' ..l r1.. Li setancl c cri ri rr. '',rl t, t r r t t lt . ir l : t r t rrttrl i tr"(i r)edi ar ' rl C ,S C rj se .rl , :r, r ' r lr r l llz lt r i s i n l l i l rt' 1 r' l rs g rri n i tq l rtt C rr r.gl c ). rt1' r.i qr,. l ':,r:l ri ,r ir l: r . r l: r . s 1 r. rrs ' r,i l ri i i r,rr l l l .r,:rte a e r stul ui l )o r,cl o tl oui . trci rrri :,rrl , ri ):r . , li' I ir r r lr ii, (' r ri f(.fl rrre :l s l l l i v i l l l c i , c n hi pcl aauzi c si r,.r al tcrrr.r,rr lr,tr.i l: u. r r l: r lr , r , rrrtl q .rrn g l j o n ri lg c n j c n l fl t e s te deosebi i , (l o tfect:t1. N l l '. ,, l L t r lr lr ipo : irU l l l l i rr Z j f. l .e $ D c c ti rri n l l ,. l i carc:l :ri t()],tLct.\i ri | rr]]i Irri , , r i 'i .l ) ir lr r r lr r r ril r rl t. c rr l tr,:' 1 rez so s tc r..T \.0 c t,scl epal ol og,i cc | cs1ttrrrs:rl ri l . r'1 , || lI r r , r r l^ r . t .l (' trrr,r,l i o l l i r1 ,t, i t]Ite t,i o t,)]rt c:ut sc i dl tri ei .t l )i rrl ri i :ti :r l :r.r:,1 ;rlr r r ' : rr t iololic r.l i ti .i l Iu j l l c l 1 . D i tg -n ()s ti cl l l ani l i ()nl i c sri l l rrztl rzri 1x, i i rrl rl r l{ . r r l r l I I r cl j rrIIri .i t,il,l g rrs l ,rrl u i ,a l s a l i vl _l i ti si l t.l l l zl l l l ti . l l ) l, : ir t t t i/ r : : t ti trrrl r d .i ttrt[.,l u l i itl c rto " t:trl , .t!l r,l i ttr, f]pn1nt. tl ut(i hi 1tlrl ,1 ,'t I't,, ' nt t t l . lr , ! t i t lt ,L l tl l tl c u t)d u .l i n tl )l tl u l ri i i rn pol l i rrrrr.i ri nl i ,l rsi ;r1r,rl i rJr l l r r r r lr ir . r iit lr l i i , l l i ti tl i z i t, l :rl i ;rl :-r t rrr rrl ,rr r, :l r{ j ti tzi -l i l t rl i trri rrrl u.r,lrl l,r.r',;r rrr r : r l, ulr rri. i r r r r r l i v rri i " i ,.l i p s t' s r l rd l I,' ,i i l i k , il r l i i r,r,i nl rrr' 4i l ri l x' r' rr.rrzrrr.. I 'i rI r l rz r r lr r lir r lii iiilii l l i o l o c i (,rl c l i rri l i s i ,i o l a z r)sl { ' r. ri rr I ccl c rrr:ri i rl ri sr rrri l r,, rl rrt l tr' lr t r c r ii t r l r l i rrrl i l r s i l rt l tl l r' N l (, rrrr,t,l ri i rrr,,rl i i , l ,l o (j c s { r: i l ti l ti i r, Ir'rl Ir,I r I oI Lr I r I r 'I,I I II I | |I I I i s I rI{, IrI rri I[r,rr1 l It 0 s l l t I )l t t.t,i ti 0i i i (,l .i l \,r,f]t(,t..Mi i I ; ll rl ro r i lir t r , r i l' il. ( ' 1, l l l ti (t). l ') l, r ' ' it t nilt : , il trtl t d i tl rrl .l tl i tl t ' i rtrttl r ,or:t.tl tr I i ttt 1tt rtt tt | /I / (l t l rrr Jrtrtrl l r i | | | t':r(,I || r| :r| :i ) i rr l t,o rl r' l r' z i rttrr r o trr I,l l ti rr rrrl l rl :t l l ul l i ztr, l tL,ri rl r, I t{;

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r.l rrr' r'\ l l:r, rrrl. tlrr : r lr r r r r r . . r r I r l, , , lr r , , r . ; , : r lt r l r . | r , l ; r i , r r l t r r , | l r . I I | | I I i r I I . I i I I i | . lr), lt r rr lrrtrrlr. yn n.r ; t l, i t r | , r tt t , rI , ,, | | t |t , l( , l) t ! ) ( {. - t {. I | | I I I I r . ; | | r r i . r r f r || : 1 i , I Z ; l | :ttl, ( r l! illrzrt I;rt,i: r I c I r iI I r I r , r l I r . , r r r , I , r , { li j r l l ) . , i ] r l l , r . I l ) : r J . l l i r : i i t r r t l i l r l r . rll rtclr j t,t:lli(.1 i. r \ t t t ir r lir r r 1, , , lr r r ,r li, l, . r r . l l l i r " l r " . 1r, , I r r I rI I rr, t rI I I r rr. r r . i I , . I r rlr' . lilr l,;rrrrllr (ilillr r iu lilr lr , , r r r r r r r 1r i, . l, , r h , r l i r r , r r , . L , l i r r l o ! : i i ( r i l r l r r . , , . Itrlr. r' r,1.,rr.. lrr.ii.r') , s lr r . r , ' ir l. z r , lr , ll. r ir r ilr . r , l s i I i i I , I r I r 'r I ; . , l 1 ) {i l ) . r . r r r . r r r , rrrrrloz|lI iIlillll|li\(,rli lr r z c s . : r . _\ ( . , , s 1i.lll. o( . ( , r - , ! ( ,, ; r i u \ ( {, 1 ) l i i r l x r l i r k , r | i i , , l o r . r 1rolir.11 rli1,1 1l1 11 11, t ' r . i1( s i ior nr ( ' lr ir r r il( l( , t . J pot }r o d u c u L d " r , , , , , , l)itr.rrlizit

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' :i lLllri. l vt) t) t\!.l t'r i ttl N l l I 'u . t r tl i :i i l t.l i u ti u l .t l r tr xl ttr r r tl c l tn r t) ti h tn i q ttt ( l r tr l l r t l tttr to t i g _ l tl ttti r tr , tt( 'tl ti l !o i l tr l ( ', i u r r ttt|i Il r r 'r t l r r r l r , rr r r 0 i t l r ', l r ti ^ tl i tl g i o r l l tl |, r r f i i " ; r r ') s r r r r t,tu l i q n t ( cttr t.i ,to i i r r ( ,, l r tt!r l |i l r n ^ l r sl i r l i ( 1 ( ') . r i t' i ttl i l r tcsc i r t: tl t;tl r r ,l ,, l t , 1 I 'r l n r ti :i i i r .l r r r i r r l l r l i n Iu l .i l t si xl r n ti u | | | | | ' r | | , l r . r ; I r Ir l ' rr r' I r.r' i rrI i i , r r l r .to i r i i |l l 'r ,tj ( ) st,l |t'o zi ( 1 r t'i tr l fzi ttn i \'a N |l tl l \t|' r r r 1 r 'r r r r r i r i r rl ( r .r 1 .l ,r 'r l ) , l r .ttl l tr ti i , l r r r tl r t l tti tr l r i tl g l i i tr , l ,{'fi :t1 1 r 'r i i l t r to tl o u l r t, 'r ': r r r r l o r r l r l o z:t l tti Wr .r 1 r .tt't ;.;t. ( .l r i r i i , r l i t,l t,q i r ) ( l r tn r l i :i l l tti l l l ) l t l l t t t t li .:;u .l r r ti tl i ,,i tl i q t,tl i ci i " r l o l tt Tr ti tt r '''.L ,l ttr l tttr t r , 1 , r 'r 'z i r r l i i o r r l r ,r 'l i tr tr r .tr l r ,:r l r .i r l i ;tt,tr n l i l st'si r r l i i l r 'l l l i ',, r l i tt i r r r r l t' t:tztttl l r , r L . tl|tlttllt tl i tl ) tl tt!t r r i , r ' l tt l ttr ,ttl ', 1 ",'i l t o ti l 'i l i l ttl i l r . r r r r l r z i i I r r r 'r Ir Ir . r .r IIr I r tl r .l tl ,r ' ttr ,:l l ( ,r ,,o r r r r |r r r l l r l i zi i l ,r r Ii r l r i t.l i r ,l ,r g i r , 1 ttr ,<r tr l l , r l tr r l ti . , rr I ro I rrr I i l r , ' 1, r l i r r l r r 'l i r l r r :r r l tr r l :r l n l tr r ti l r tt{i ttr ' l xr i l i l r r tr si r l l r tl r r 'l ':r i ct tr l t, l 1 l {l l l ; Wo l l i ,tttr r ttt, , r I t o 1 r I r i i l r r I { ' t i r I }|.t | ,| , , l 1 ) / i : l 'i r l r l t'1 , l l l 'i Ii

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r r| | | | I . Ir' { |:I zrgorrrrrliIilor, si :r, iilitioulalului buzelor., (,u drpltsar.et g1lrij). t), ( , r ' ll n ir i r rrrrl l rr ri t,i , s 1 :a s n c 4 c s i n i t l t:d:i rrsate fi {te (.rl l l t,i l ,,li j l l \ r,rrrti r ' ( r r l. r r r r r s .rrl l tl r' .i i r.i l ti r:c ,1 i ;s a ri m:rs1i rl i rl uai i . f." .i i ,i " ri ,r' , o r':rrr:r|r r , r r . : r I r I I r r i. rr r,i rrl a tu l u j . a l i s u l n i , a vorl l j l .i j si rl ut;i s1" rot1i 1,j .;i trl ,1 rtr.r't : r s ir r r P lr ' 1,{ , \ (,i l .ti i tc .trri .r,. ta c ti l r, ,l , 1,.i .,," i " i ri ,.Ii .l a:rrrr.erri rsi Li .r" i r l rrr lr . : r : r .rrr elior tl rz i s j tl i l e s c s p a s i n e l e . i _ tn t,ol i sc rcrnn,tl cazi i .q,,r,u,t,, 'r'r(' r r : r r ' (: r ir * r ' . r . r' rr l rrl i ' i l l te l t s p a s m ri i tri tr ,,;l rt. 1r;| ,r" t,,,rrj 1i o r, . ri ! | ; rI rl r Ii i

t,rlrlrri),i.' .s.r,liti rr, l.ont:rhrl,i. lle.un fontl O" ii]u,.ir,,, r('rtir. ro lrrrxlrrl slrrrli, sccuseparl,iale, cind po"oriiro"ti"'Oi*"1"t ur ,.r.r"qi.fti, cr,,,i lle iill ul. . r'r,srrlrr.ilalt,, i.tt,o rlt.car. (i. scc.se dezorrlonateri1i1 r.rr l,,i;1..,,', ] ,r r.irlirrr ;r rr.(trr.( rl tL,autr.itie,c:Lte itrtertseazii pe linrl inlr.eaea rnust:trllr Irrrrr Ir.rrrilrr.i;rrii ;i rr, rrilrrrlcrr. rco\te criz..u'r,irziL urecl.i d,nr,oit.rrr rLi.( rr(1r,, rr;r'rr:1rr'lrrlrr sc r.rr r.,,i'lrciiil,, tn ri.,"_ci,ro;"" iliiocate Oe ,lx,.i t:rlr:r .lr..l :r r.,r,r.rrlrri. Sc..onsiatri ;i p"ez"n1ait"i-siricrgirrnor.rnal,, 'ir.r'i l:r r.,rr tr.:rr.ii.r I'r,rlaiiilui,," ur,,,,iirri*",iri',i,i'"uon,r.a,,, ,,,. l,l, D r, ||1'.t,t,. r:|l ||l|. i r . l. , 1 rtl ,.,r,.1 ' rz i l o r.h i u l u i . c i rrr " ,rzl , l a or,l Izi t,,,.hi rrtrri .,.,. ..,i ' .

I '1,,1, lil:'t,.:1i,,';::';;1";,I,iilJi,Jii1",Jir:;:ili,1t,tiill;;lllil: 'll,l"lil;;,Xi -tiii ,]']l:r[,' :r,;,]rrLie,r1rrn,i t; cil,o-a o"o;.l, p""ii,o,i,i lr.ax tm,.i rt,.rr,,t )'.1.1 .,,iill i,'t,i. ,rlii ii,' li .i,i,1i"ilii*i,i!i"Ti'.i1'.;rtil,.]iiiil"il.:i.*iiili';T ii,lillxl;, -

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\ , l l r a s i ttttl .]r r t:i tl t,o r ti tu tl tttt t,stt', i tt tr r l tl i l l tl r ^ , l l l l . sl ) l l r i tl l l l r ( l i l l ' r 'l 'r 'ti :ti stttl ' l ti i l tl ttti l i '{r 't t , r , r r 'l i r t l t, o .i u l ;:tr tn i ttn i i l o tr l tl i zl tl l i l l t tr ttt- r ( l ( r l l r :t ttr \( 'ti l l l l 'i l ttl , 1 , t , , I r | | i s t iti Io tti Io tItItIi ct', cl tti l sl 'tl i l i 'ttl t( i tl 7 'i tr rrrrl i tt p tr xl tt|r ' st'. ( i , ( {) l l l l i l ( '!i i L ttttl si 'tl i r tl 'r i i l ( ' I1 r l ;l , t . . i 1 r | i i r l l r l ) i ti l 'i tt a t,l 'l l tsi ti tr tl t o <'l ttzi l t l r l co l r l x'i , ||Ii I( i II|':I ,r,r, r . , \ s l 1 L .j . tttt * ,,,,l r r ,'tr i l o l l r r t ( l r r ( t sl l { r '( r r tr l r r r ' p l i r tl 'i l l l r i i u ttl i i , t 'r ', 1r,] f i , r ( . i s i ,,r l ,.i 'r r l ttl tr ca " "g 1 1 ' "1 ,,t, tr tttl cl ti , i , r 'r 'i r l i l oi .i i tcl i so tr i tr tl i l ,, 1 ,,' 1 tt'r l l l tl l , r 'i i zl t l l tti i ttr l r r r r '' 1 r " r r r r l o t t t t 't r i ti l l r r l i r r l ttl tti i r r l i 'r 'i o r ', i i t' Ix"t't'l l r l l r Il i i r Iti Itti stl p 'i i 'r t, 'r r 1 "' l , r l r r \ 1 r 'l r s i1 ' 1 r r ' It{,r tti tIr I;IttI 1 1 'sl ) ( 'r r i i \ ;i t'l ti r tt i 'L r g ^ 1 '1 1 ( 'l l l l l z:l r t'' tl ) 4 r .n " ( h 'l i l l tr l i l l l l l ( 'r i r ) t u l l tr i ]l Ii l tr , I f ) , {T r r r .r a l r / n tIl i ttt ',1 ) tt'r tl r r l i 'r ' r 'r ;1 r 'o i 1 ) l !|) , , , . , 1 S i r l r r r rl r i t I I rt t I t t t ' rt : t t t , l 1 ) 'i i , r 'i l r r l i tl t' Il r tl ttl l r r ttr ' ;tt t l l tr t i tt r I t I t r I I t I t I I l t tl str i l ' ' t , l t i l r r l r t r r l i ,t'r r i r ':r 'l tr tl Itttr '1 ,i i ,',,,i ttr i ,'l r t ; , ; tttt'r r ':l tr sr ' i r so ti i t l to ttl l r l i l t ttttts,'l ti l r r t r l , , I l r r I r I t i t I Ii r t.i tl l tl i ci 1rrr1 g i l ttl tti , t'r 'r ':t si ;r Ir r l r ttzcl o t ,,, .r 'ttt1 r 'r tl t' l ttl l s( 'l l i l r ) l .IttI'tIIo ttttItr i rl.Lvr." tl I sl tr tu tr r | ttt ttsl t|r 'l i r , l r , '. r . r l r ) r l i , tl l i r si i Ii r ' :ttti tttl t,l l i ( l ( ' l tti i ( l i l i ' ,l,l I l ! l r r .i tr l l tti ,r tl l r .t,i o t, ;i r l 0 st.r .r |r r . 1 r 'l tq tr t|tr l :ttr , ( sl ttt Il tsr 'i |ttl l r l r r ) l tr i r r l i ,r 'i r r r . { r .i zr .i r ,, rrr. i r r | | rrr, t rI i r I ( ' tl |' r 'r ti ttl l i , r 'r 'r l |l tr 'l l r l tr , r r , l L r i l i r r , i lr l Il tr .\( l t'i - l ' I'i {l l l l ) l l r l l l , , 1 , r , , , r r t I r , z i l i r , r ,ti zr r l r i r r l l t si .i ttl 0 r l r 1 r 'tl tl r 'l L '( l ) l r ) 1 1 1 , 1 , l ' , ! r r r i r o j r .r , i r r r cr i ,'ti i ,;r r o r l r i r i r i i :t I rI i t t tl I r i ; t I i r 'i Stl tvi tr l l l t i ttr i tt tztl , , , \ r ' l i r . l : r li l r ' Il l l zi l r l l ) i \l l l tl i i l i l l ttl i l i l l r ' l l ':',i tttti ttIt r o l tr r ', r l ;tt r r ' l r r r |r ' I I I I I r' : | 1 \ i l fi ( 'l l l i l l ;i ;l i L l 1r 'l l r |l :l l i i tr 'i ) Sr ' l tr r ':ttr t\ttr \ ' I I , I I rl . r r ' i ,I r ' r I , rrI t , 1I t t r ' r )| I ', :r ' l r "r l L r /i r 'l r tl i r r ': Llllr,tl\lr f r r l l l r r 'l r ' l ,r r :u , .l ,r 't,r [' 1 t,tl t n l tl tl i l i r t. ( l 'r "r 'l r r tt t l ':t i l l ' l 1 ) l 'i l l ' ' r 'r l l r i | l t l l lr c r I r : r 1rr t I r t rr t r I Ir|t ( , 1 l l 1 t , r :.tt,tr ll ,tr t,r l ,l i tt |r t:;tr l tttt"t : i ttt|||'tttt|t l 'tr l l "' l "'tti tr r ( r ;ti 1 |L tl "tr ', i r r r r r , i t r l r ', r l r t, r r l l .tr r zr r tr tr r l l r p l l r , r l r r r ; LI t t r' ' r rI I rt | | rt I ) l l r l l i r l l l ( r 'l l l r '\l l l l 1 |l

i l , , l ; l l 'i i i :,i l l

r tr It.ttrr'lrtli' lit.crtttt si setrz a l, ii ,i {1 ' r' r' lr' g irr, ' rs r'. } rrr. r' 1

u r ) ii l) ( ,lit;r\ i ,t, ,,,,t,s,,1 {,t.tz(,t (.l utri (.t, i . i , | \ i , I | | { | ( . , . I , , | | I , i r r i| l.r . tI r .r r 1 r . 1 1 ,i ,,.l ri l t ,,rl r, Ir. r , r., .,1 t r' r \ r, r/ 1 . l r r l l o , . 1 ) i ll) ltlllr .tr l r .,r l,o s,,lr r .r : r,l l ol rrl ,,r I I \ r . , . I , I i 1| I r. ) I rl ,. lirr. rl l r : r r:|| | tll :l| | r . .1.. ,rl |,i l L lr r r r trl , lr :r ] r r tl l,,r r l,, ri ti l rl l rl 1,, rl'r n, i l , r i r l t l.,rlirl :l lr r \ i r l:,r r :,1 lr ,,;r lr. r rl ,,1.,|,.:,, 1,:r r,r|l r' , . irir

il, ( r l lr r r r lj* p l ts rrr i tr.i n ri 1 .i t rrrr s l to rrs i rrl i l i r.i rrrr l i ,l rl i r ]rr,r,.rl i zi l , 'l r r . l rtr r:rl r ' r r , iilllr il i l trl .l r I,l .r,1 ri .ri ,l I)(,r.v ,l l ti i r ri ,rr* ,,l i i 1,,, (,;11. Il l t l ' (xl r ' . tr, | ( r . \ r r , r lr r r r lr lir r,.r,r,l i il,ri p l r,r,rl i trri ri l i l rl r.). " i i ,rr l ri i i l url rr:rl i , ._1r:r_rrrul . .r)l | l l l Ii . .\l i rrq | r,r,tr t | l rr;i rlt 'l ri l rrl l ||r it t |ll||t l . i rrl i sr,;rri l ri l t Irtl , r.rl rl rr,.r r, iDrrr'rI r ' I r , . | | I I | ' I I | | I I r , | ) | l rr ,| | | | I( .( i( |

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I Ir . I r l rr | | ( | I / i ( : t l : [ ' ( ' f r i 0 t. i: irr lr! )l | | t r f l t l l r ' r ' l | l . illi\ (, lr r lr It | l | lr .ltr ( , (,|,(,I,t:II, (.u (,{) l i gl l |,i l i ,i c (l I

::.1; . 1i" S ilr lr ' { r r n u l l u i } l t' l l i c rs s o rr-l l o s s rrl l rrl ronsti i rl i rrtl o ptrr.;rl i zr,, l r.i rl i i ir lliliu( jlc lr li' , a ,d e s c l Iri Il I.r' i rIr' i , c a rc s c r)or)tcrt' l rcl rr rtrornri rti rl l r ,rr i l rr ir r l( ' r ' r - ul(d0 | lu n i s a u a n i (S n l r| r' rD :rn;i l l e nte, 1gtj 6; ti r\-orn(,rJ l J)(i t| 1. IiIrirrrrrrrL'Irr l)ilrll,li1]iccse pot insoti do urt simplu ,,bloc de r:onrlucci,t'., r,u r rrrrlclrrlo loilrlii, dllr cu ocaztia repetiil.ilor se pot ilrstir]a yali$ile grllrrlr. {li. rli rr.r'\.r1r J)o lnUsctlatura faCia,li,,Cu pareze reziclUirl. si cu Coltsl,(ruli\(, ,1 r:rrrr r rlr ' r c ilr lc . A pt r e d e p re fe ri l tl l a fe me i Si ]a. Ti rsl o tl ai 1i ner,t,tl ,r,rl lr ;rrrr':rl iz ir r r i llell. Ro s e l th a l (1 9 3 1 , c i ta i j d e i l l a verner, 1969) a l el atat crrzrrl i r || irr,irlonlir l'utniliale. Acest sindrom se insoteste dc cele mrri nLullo rtri si ,l ,,.,l cr r r r ' n, . r llr , , lu; r s o i l (.i c t' ,i ,.i .rl r.h rrz e l o r' ,c ar.l rof l i bi l ar..r.:I,..r.r, ,tr.tl ,tl rrrrr|r'rr Ir'1oi, rftial drc:i ptlr:ilizia fuci:r1[ este Inilaterr]ri. [-rr rl lr.rril0rr rru p l o r r r , ( iille es t e i n s ti i n c o n s ta n t, e s 1 ,e re l rezertat ri ,,o i rl j cnl i i i rrl c rr l i rrrl ri i ( lit r lt t r l) lic at u ). H a l e o ri tu m c fi e re a fe te i poa:te sr' L l i tei " url i L l rrrrrl i zr:r l rr, r:rl rrt r r llt r r i s it u l n i 1 1 ez i l e , p e rn ri ti n r.l u n d i agnosl i r. rctl ospccti r l ' l ,l \, r l i r' , 11, ( i1) ) . l.li.7. Sirrlronul lui Xloobius este o rar5, afectiutrt, {.(rlgenit{ iiii 1l(, ,l rrrl o rlic ir r r , : i r r c ple c i z a ti l , c a re a s o c i t.,z i o i , !a l . l l l ' zi p l tLrxl a i tni - sau l )i l :r l .r'rrl :r. c r r llr laiiz ii o c u l o :n o to ri i (i n d c o s e b i d e abi l ucens). :l.li.l|. Sindromul lui l{eerlord leprezintii, o cor}rllicalie treulokrgir,:r :r rrrtrrirhrzci, irr cnrsrrl cr[eia poate apirea o p:],]alizic faciali peli{r,r,icrr :r rrx i rrlr i r r r y r r r lot irl i tr' is i c u u v c i ti i ,

r zi( i. i r r r t ; t t t lt t t l ,,,i ,,,,r t" " ' i ntl- o cluzi lpar cm il, t t ll( 't t i lr r selr iubr t . l- r ': '; " i ';;'r:l;;,;;,r : rr)itr lrrrrrliziiti si cliolosii "i diYflso i i*r'iriit" r rr\r'lrtli{ "p)'1t'iii', ill(" ilt t'tllsttl (tluT)al lttrntttttils-" (''Taniocorcl)l t, ittnilt |.s.bit'1,tttic r r l' "t" L zit r t 'i ir r ilr " ,rrrl l ol unol ttr r1 e hi per t ensm nr '- it t t r . - '"n"i'"i', ir r . lllr ilir r l r ''r " ( t r . r 't il. r t . r t r r i : b) i. ie: ii', r t ae n?r t t illt i. t 101t st i( i ' , ,.i i ' i :,;r;;" ,;i , , ; c. j l l oxi ce. r r culiloam e il( llslit 'r ', lur llor i si : r llt ' lr l'r r ( 't r \ r "( ) I ||I I f |sI \I r| ,.| | r0D l rl i i
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('lr' (('/?'-/ir' r) il. 1c;iir,i1t '|t.t'4.t.tti ;;1";;;;;r:o *" parult:ii ltrtt tirllr ill lttitlt ,lLrclsr ei iologii, lltcnl,ron e:interluj;11) sf irIir( r' : it' inrl'rtrmlrri,t trspt'.1 ')i (t\tt't'tI /,,:; ;"it';ir;1i;;iilrir iii.r;"rtlnt torsori ai f (l'ilrltli( , i',, crizclorniQrr'nout7;rl) in cursul unor' tt'( "i,r'rui 1li?S; (iastaut', l9?3)' .19?3' , r.olirb., "ili r'li'rrtt'ttlrtt (irlrrclr'r'\ {zrlt' ?lir,:i""i"t ,i,,ii"l :rrxlitiie l'r"zinli.rr,rr
, t , t t n r , l t n l 'o t 'i t t l t ( tr l l n o r 'l [e m p n ;ttl t, l r l c t r u i l ci l r r r l ,:r zr r l i l ( Ar ''n n i 'r r " ,'iti , r 'i lttiili'";t'": tu n "'r i - :r ]r ' 'i ( 'l r l r '' vt'i tl r 'i r r tl r tl tti l :r ' t' l :r r /J' rrl lll l 'r t'

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si ir lrrl irrti(rtro Lii illinri(x tsirtr ,l,;i;;;;,,'i,,i,,i,,t"],:',i,,rt irr absc i a hiperltrr rl :l trl('r'ir tlo s ttrttr str tle rll'c ;i , i;;;i;;;'1-ii :'i-: qi, ile obicrri,so acompiir i:'t'zii ';; ,l, 1,r,tuporal. ' lolr ' ")';;;;;;;;ie sirtl' reprezcntatc rltr zgornrtltrtttl't'itctrtttr..tr' i:\ ,,oltiectit'e" urehro',t srttt tl. /ir/rrir r'rrt't ,,,,.,:;L,i;'ail,"htl,rlllii'ii,rtt-''ito.i <lt i'rLllittatttt:
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'\ . 1 . 1 . . lIt]t:.ti o e u si 'n tTtl tttttt[o r s h i tt:l i tt' l ttzo ti r '' t[i 'l l l r tsi ttr ' tL ' 'l 'r . r i t r t l , r t l l t t t t ,. r 'l l tr ttl l t'l 'i z:r 1 , l ) l j l l tl '( J s( l l i zi tl i ( ' ', l ) r ) l tr 1 r \tl l l l i \r 'l l l l , ! , r r . : r . . r ( , l r i r't'1 t h r t' j n t;r l r {'l i ( 1 l r sl l l ) i i \'1 u l si l l l l i i Ii l l l r | , , . ! l r l I r l l r s{ l t$ r l r 'l r l 'l tl i tt:ti , tl l tr sl ' i r \i l ( '( 'l l ) l 'i !zi r ]i l l l s{ r r r l l |l tr i :l i :r rrio(lrll , , r r r r r l i t ( l ( l l ) t) zi l i i l ( l l l ) l l l l l i j l l sp tr .l i tl . \'( 'r l i j r d l l l l i 'r l ( ', i l l l l r 'l r ( l i r l ' ( 1 " o i r ( "tr l l r ( ' l ) r i \'r 'l tsl r ' tIr l sl i l r l t'cr th i l r tl ttc '\tl o st'r i ' . , 1 , l , , r i r 'l t t z i r t o ch i l o l ;i , , 'l I r l r 'i t t c t l c zct'l tj l j Jtr tr , l ) L l i i i l l ( 1 tl l r 'l 'u ( ' l ) i l l i ' l i r ( l i l r l ( 't1 " tl :tt l 'i i ti Ii .tr l r t':t ( ( ,1 ( ,t'( ,,1 t,i .r 1 i :tl r l t. ([ i i I i I l I ( )i rt i ( I l ]l tl i i t1 ' Ittr i tti l r 'si :tL r l , ,1 'r , ! , ( . , ', r i l i l r l i i I l , 1 , 1 r , , r .s i s i i u ' o p l l r ' \r l so vN g i l l {') ( l l l p o r - i tl i r r fi l 'l l fl ( 'tt.,1 1 1 1 {l ; l 'r r ;r o t'r r :r r tti 'tt * r .r l ) r r i ' r i , . , l r r l r . , l l | ? $ ) . 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( t l ( '1 ti . l x) l l l l t,\'l l l l l r i sl r r r a zi i ' o l l 1 ) zi l i r r i ttl 'l r i l i zl r i i t, \ r 'r 'l i .i l tl t';r l ) l l l l l i ' i l r ( ' i l Il l i f( Il l i ( 'i t't'l t l i tl ti ( 1 . ( , . . r r l r {i {' l l tr g ,i r r si i r ( r tl |i i ,l i t , . r r r r r t r i l i , s l l i 1 tt:i ttl t . sr 'n zr tl i tr l tt'r l l a l l i ,l ) r 'l l i l ) i l r i r .- {[( l tl t''l l tsr t.r ' si r l . r l "'z'' , t r l r l ) r . 'r . l r .i r r ,l i r r l r r i . ( ,l tj tr r . i r r .l l 1 'l tl .'( .i i IIr .I) i l i Ir i !i r r r tttII1 1 'Ir '. 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l l )',:i ; \ t i! , x f Nc lt . I i)? 8 ). 7-, I t tlil_r'lt wltIi.t'.iJorwr., cnrat;l,efizate pri'tr_o mrre srmililu(li,rj .' :rl,, , jr' \r.r'tr!: rrr:rserlilL lrr,r,r,lu ll.jnidre, se datot,.sc ltt\or ceulc Lrnultt sar. , \ s llel, r lc i i ,l c (N l ,e rn x n j fe s l i ri v c rl i gi ttoti st tttttttl t. si rLi , rL, rnul l ,c ol r p rr| rr"is ljc r ' , r ' 10 nu a u _l tu i i i rrl i n c i ta rl ,e a c ri zel l ur di rL bui l l l r,.N [i rrri r)rrr, I)rr i Iri r'Ir.' r r ( |irlr Jis t lulnlls u l , L rrl l [rri rti ]c tl c c c l i i l i ]rr:u l ani ffsl i ri hr vogol :tl ,i vI ryi ri rtl i ) r lll' r r r i r lir c ..r.' ,\s r,rr,' rri ' r,rn u ,rri l b s tr i rii nrr' i r)ri ri rrrrr. s. i rr,i rrr,s. t.tl.,'itrl,, tttrlt:,,,ti rrr.ntit,:r,itr |ttl,4,t\tl.t,tLbl,, i\ lt,ou) ,el,t) rrdirslir;r,, itr tttroltr .,,i .!,',., , ! I , . l. \ |w' 1l||ll ' | ' | ' ,\| l tl l ,1 ' ' l t' l | ' ' | 1 1 l t.rrl rttttt1i i l tttl tt' l t' dtrt4| ' dri | l | :l !l ' | ,.l ,(| | | | Il ' | .| | |l i r\\ l tr( , t . 1, , i |lt irt, , l l )ti !); l i ,i rt(fr, l { } ri :.1 ; l \l i l i ,fcsri rt, l l )?S ). I r r li. jt lt , . t lr u t.u rtti (ttl tn l th i t,i ttl i h,l t, l oni tt ). N l rrl pl :rl ri r.i rr. l o j ;d x .l l I t I r'l r, I rrr t l r, t r . r l: rlot t.,k . l rr, trtro r.trtr.rl i l trrl (\1 l ,r, 1l l (. I,rr,,' .,, r.1trl l trt)l ' r.l lt I t).t rt!

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ir r t t I r t Lt t r I , 'r 'I t '' , t i( i ir t : r ' r . t il'lr r t r t r t , it t il' , | l t, I{IrIIIIIrIII,I r |:|L |1\ l I I i( 'i | |i | . ( 1lt it r i|llr r ' ( 'f r llllt { ' I llr ! ' r lll( l\ lt r illlt t lt t ot I it r llt 't r zt 't t ir r i) , ,,,r,l rrl tkr | l tt l to lt , lr r ollt t qii vr . siilr t t lr r t . si I t I t 'r 'r 'I t t I . I , t ' ;,r,rrl rr.Ir,zi rrrri r l. g. it . r . lr li'r . lr l. I ilt , 'r 'l. r 'r ( ir v( , ils. : r,ql i ornr.r,. l )c iiqr t vlr l, i. iit l diu ir r liixicr r iilt ll, ilit 'ii r r cLt la r '( 'r r slilllr . r '' l ' rr:ri I i l ri c c\cnp lu. r 't 1i. lc t lo r r t i'lit r r ' ( '"ir ': r ' S l rr:i ottti ciia llr o( hlce ( j( lo r n2t i f r {l( '\ - r 'll1( vt 1 t r lr t t r " \ r 'r ''r lr ' : r lr : t iilr r t ' r 'r 'r : ilt nr oleilor ' illo |i 1,ri rr l ,' zi tttti l e l a bir lint ico, sjnt dooscbjl; r lt ' ir ll, t lnst ' [ l t I r llt it r ll i t r1rrr i I rI il i rri l i ,sl i l i l ttrt ig; inolse 'r Il i Zi i 0).i rtsotj tr : r |cnlil] 'jt lll}) 111'ijr i( |( '}}}lJ's'( l|, 'lljsillI lllll|] |}l'I Zi''I ljlI ( t lc ol) i( 'ci bi. iat r elal) ,glcr r '{: l si vr ) r r ir ir t t ( 't r i( "l: t . r t t . sr ' ' ,r ,,r' i ,r,,ti l l t,' gir : i1( ) l' si t jnit i1 lr r {'chi. il'ulbu. iI 'il. r 1r t , r 'lt ili}r . r rir i t ll t r r . t r i i r: , r 1i1: , . 1i t,,,:rl c:rsr){,i i ! I () 1rs(,l l ri soiizr it iai f lo r - cr 1, ij lxr l, pt Ts, ist : r nlli r iiult ; ii Vr l'l! r r " I ) r r {r 'lr lil t,,l l rl (1,i l i i ,i 1i i l e zjr r ir ilor si u . 't r ilxr r r i, 't . ir il- . t 't i1t ilir , . , s*. t xilr 'ilr t lii r t lt t . t i , r I' r,r:r i l c si sl ,erl lLl izlt t 'c l, r iLsllt lst r iilol'la pr obt lc \ '( sl, jhlllillt ' lr t 'lt 't r ''t r r l ''' ( lel( ] r i{r i t olir l{'r i( ', lJI rr 'r r r r l ,,l ,rrUfi r, l ti po- - <lt i it Lcr r t ii: r ir ilii: t t t l. t 1n'ollr , iir - si {llt ulif ouisli, llln( llir alil'r l( lllir r ll'zit llr i : r iil ( r 'lr 1r 'r r lt " ,, rrl rl l rl ;i zl l ri 'il llr iue( t ( ) f r it l 1r r t r lilr . r , {ir , . r r 1r r r I r lr r l , rl si i rcri j i Itt,i ,) . I iq, t u. nt it in, o. . . int : r t t it iit o ir I ( , 01n, i12i{ t l cr r r lt 'lLr ' lr t ' ,,, i rl ,1rrr' , orl tt t , it Lr llr c lr t it . t rplilr l iii1- 'oillLt zii, t lo. pt 'r ir r '1. rt1ic i ri r lr . , I ) ( , r 'r r {'sir ', , 1 1{') $1 l, ljr it r t r t l r i r i' lczsaziL ,,,,i i i rrtr' ,i l l i l r,sr , s( r r , i1r ! "ii) , r' r.,' ,, { i i i l tl tl t : Llr r u't . lt onlt rr l r olt r lr ', l1}( il) ) ' '( ; t r t plt lt t t it : it t lL' 1I ir I t I t t cit I I I r t t l l t i .tti ,,)ut.'- a: r ar ljlr lr i iiir 'lr ilt t il( lilr il ( 111 r,r' .i crrrri i l t' liliLnillosliir , j1: 1'1'l'ilj11111r t : r 'lr t t r lr t lr " lit r r Lvell'l. , ri ir i l. q: nilr liI t 'lr ' i, olt , nzir '; i zilr t noir l It I I t i t I t t I It I I ' , 1lI I t t r r i: l r oi i l i ' tl r gfl 't , r lli, 1'l- ir ) r iii, 1irhilr ' I ,,,r.,,,,,:i zt' ,,i r,', r iicvli. zil. . i. i. l: llr ilr 'r . : l slilr iiilr r ili. lt r sr , llir nlt ,it t i t t1rI I it 'rI rrIr ( lo( lill( '1lI r i it 'r 'r l'r 'silt t lt " r ; ilt f ,rl ri (rr (i l r r:l ;it Lilt i. llziililil{l l t)" ol ost,{t'o't . Li}i, lt l( ' : ili\ l1l si lr r }iit it r t t t l r |sf ilr r r llt t ' III rtrI t r' ' i t r' I r 1 r t 'r ( : r l l rl l l i , r' li qi ttrl a.srr l tl r ini r l( ) ( lt 'ill11'.r 1, r ; I 't r ir jr I i] r 'r t ill t r ' n'r zit ir r rrl r' 1 ' ' ili, 'i'ir l, : r r s'r ( ilr -; j 'Lr ''r ''r lll'r ' si I t iI t o|t r I t 'r r ' tt,,i i i i n rl r:r:csrt,h^ 1, ip t r x'nii. |l it r r 't t t le lt ili . gt nt t 'Lt 'lt : N f.t" i l r:ni. f r : *li', t it t t t r lir linr : o. : t e ( jit lit : ! d ] llu( hr ( 1o lil ut t ii lt olt t r ll i r r t t r t liiit , r t r r l' r) Il i [tarl t : r t : 'it , t t a( t II i l i r' :r i r' l: r I rt I I 1 ,1,,ti i ,i Jl rbi r;liillr r i r I , Slilnr lr r r ', in: r t r jloglai. l- . r ill 1r r '1, i, j( ', ( \ 'r r t lir l ln( '! 'i r ir r sillt llr t t r li, llt qi t kr ii; sol, ir , r ' .i :r iii , ;i cr-l cit silt clllr t t lt li '' Sr lr o' ir r : r r r '''( ': r { Lt lt ilr t r t 'r 'r liir r lr ilil'r r lr ' ,' rrl l i l i r cotl si clt 't 'ii ' , , 1elsr ''or lr 'i' l l l l l ,rl l l l i l rl \ , ri i l rrrl l i | i , t,tr lt ilr olr r r zj0 r l, 'r r ' r ', r . Jr lr "l, illr 1"l: lji f i ( 'll . "- l( llr l{il{r
r ! L ( . r 'o n r !t l l l I ) l l l sl l l , ( l ( '( 'L l r l i i l l t'r 'r tr r ( i i l :tl r r t'i r u r a tti ( r i a l '( i ( L c l l sl l ) t1 '1 l o 1 l l ) ( r r r i c I t ) . II : r '1 t , ti ttt \'i '1 "( 'l i l l l \:( r i l t t l t l l l t t L t'L $ 0 sj l 'u cl tzi i , , , 1 i l r r , , i r r '1 1 1 ' 1 1 1 '1 Si to r ':r 1 ) ( ,l r i r u l r l l tr r 1 i1 '- s ' vi l si l 'tl l i ) r :3 r r l ttti ' ' , 1 , , , 1 , , r r r r , ,l l r r r t sp i t'l L i r i i , l i .r r ttL i r l 'r l i l t i i ItIi ti i I'IIr I q i 1 tItt'It1 i Ir ti r Ii .tr r ') l r ' 1 r "l t , \ " 4 , / a , : t itti i t( r ttd u :r i Jtt'( h r r l tr .s.l l i tl tt tt t r rt ri l i r i rl i i t i r ,'t'ti i g i tt'l tsr ' , , , , . , 1 i ', i r , 'l r i l r . r r,x.i i l l ti l i l l r i 'r "l l tJr i r i r l l r i .i l ' l tl l l tl l i ' r l t'i zt' v<'t l i r l ttr r r :r '.l ' i 1 1 '1 1 si [. \i tr \Jti l ,tt.l ,a ttl ttttt i \ I t r t l , l i o l tt l xr t , , , , . , r 1 , i , i t , n r | t,s, cv0 l r ti r r r I i tr l r l U 'e l tr l 0 tt va Jr tl i l t. l ti p t:r :Il i r r |r r r i r .r '. l l r :l r 'r ']l r \ , , r z r r t i . c l r r i , t 'r ttti sl i l g l tt{}l tt'i l l l l l l ,- |o l tl 'r r tl vi tl cr tl i l t o l ti l tr n tl 'l l l 'l i r i l r ti o l r l l r r , , r r l i c i i I t i I rr I t ' t I t I i i , tl tr tr l ti r ,t'i si t r tl l t i r r i i' :tt l tttl t ) l t r t t T u txttto j i l i r 1 i i tt si i tr r l t'r 'a r l l 8 l ItN ttto .l i l .i tt. .1 t( l tto |ttt( r ) tl '.i i l :r l l r tl tr i t'sl l r l r i l i l r r i r r i tr s,Ii i r r i l i i l i ttIr :ttII', t,,,,i i i l i '* 1 i i l ittl.srirt ', , i r l t r i ( r ( 'l i I1 1 !', l ) l l r ( 'r i l ( 'zl l l r l 'r 't t l i r r r i i t t t l t l i , l r r l l r r l l i i l i r L ' r 'r 'I t i I i I I l t t , l r i l r ti l i l to i i r l l i t'r ', ( l 'r r l N r vi tr i r t 1 i r r o l l l l l , l l l ? ti I ( r r t r r ( , l r t l r t {. , l t t l n 'l l l tf f! r i l tl l fi tl l ( r l xtp l r l :r l r ' r 1 r ..r 'i l r ,r l r .l r , .:r l .ti .r r r 'r r , ( l l l i l i ) r ,<,l r r l r ';r z:r . l i l i l .r .i ,ti ( ,' t 1) i sl ) l \ l r l , 'r , g ( 1 ', ', , u i , t , ', r , 1 1 ,, r 'r r 'r 'to si r r r i l :r Ir 'i IIr tIr IIi Ii , l r i p ctl ,,r r .r l r r l r i l i l r r i r .tr .sl ,i l r r tl :r l r i , 1,,,i r 'l l .r r 1 . , r , ; ', : r 'i i r i i t , i , ,,t ,,'l t,'r ',' r cr l r l r tr l o r |i 'r 'I:tL i r Ir tl i ( i r l l r f'l ) ( l l , tl i l t tr i tzttti ' r l l l i l r l r l l i l l tl r ' r ,.r . l r i Pcl l o l l l r l l :r r .i r l r r l l r r 1 , . , , r , r I L , J I r r , , 'IIr ,'r r r r :r , orrlr, Jr

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I)'l'ulhuritril.u l) il\t,lburrfu ih naurot)ollnl po0 irrrlrlir:t ln ooutontt{ l,lM olinntolar,ioc rrlitrif 1i rrultrilosl,r'1,r.i vtrr'ligirrorr,xr,r, lrrsrr(il,rr t.[orrrullo ori r[rr rLt zgurrurl,o zgornol,rl rrrrti1111. rr,rrriou. Lrr.c 5i rkl i,ul[rulrit'i do ocltililrrrr, (11,llnnitro iL ltrror Iti pot'c.soitrtbilitil fl
lirlri li t t lictr (ovitlcn!itt bile l:l prrrlrir,ur lolioii,).

(rl'(i.), tti, citrltlritrtr t[o vtlcittilhrlo: t,ttttt ll'(r1 lrtrirurrur'l(ltlitt 1u'oot'lio lrtrrgitl tlotittrtrit'ca, tlo ,,sitttlttllrt rol,rol:tltit'ittlitrt'. tirr(\il, Jl('t'vlrlui vcx(,ibt.tlar liorrll,ri ryi I 'ur liaul ar il,d!,i stmiologice: ( denumit Si.rel'rolaltirinti.c Vtti jul aestibulatr J oste tnai lttl{itt ittlltts, rrrri puliri zgomotos fi rnai putin calactclistio drxrit crrl laltirittfic. I'ort1r' ifolmr oll (!\lc('t'Jrilrilrl rrrsii, si, aib5 un caracter pa,roxistic,de 1;iprndni<)l r,rilcririlccapului. I)urata accstui vcltij vestibultlr (qi a sitrpl,otttclotrrsrr ,rirrlc) cste variabilX, in functiet de natula fa'cl,orulrtiet'ittlttglic, crtt tlrr sau chittr o irtcxciiabililltlrr vcsli o hipoexcitabilil,ato antrcneazi, 'rlricci il tle parlor lqzali. ',r.lrrt J! osibili.t d,!i 7tal,ol ogiee : (luessecundar$i ttrl,iar, IrrtloI,irIiLii infaJioctse A ) N etritelaaestibularc , lridcmicii,, herpes zostcr, febr5. tifoidri, tifos cx:urtomal,ic, In(rtilrgili lolt#rospinali microbian[, meuingiljc virotice, mcniugitc tultt'tcttiortsr', ; ripii, difterie, malarie, rujeoli, brucelozli etc.), I)etalicm rloltr cil'r,r'rr (satt neurolabirinl,itu l'uetiad' Neurita ustibulard si.filiticd' ), I'tl, nni ,rli ^) l'ilfi in ultimii ani, cste produs:i prin mecanismcdc rrre jugo-virsoull rrr stadiile secundare$i tor'liruc ale bolii Si oste car:lctorizattipritr vt,r'l,iil ,1,,lrlare Yiolen{5,,crr eri&ccrblri la miEci'r'ileoapului, olr hipo:l( uzic f i ',ll q,rrriluri in urechi. Pe lingil lista-gmus qi rlcvialia bralclor, se ovi(l(,lr l ir z.ri ,' ltipoe:citabilit al c vcslib lari. u,rliditd' sc pro{luce llr ll)roxil}nli\ I:) Meningoneurifut oestibulard, l, -10 zile cle la a,par:itiapa.rot,itliteicpidcmictt, asociinrltt'sr'rn,\rli ri (l tcziune concomitenl,i, a facialului, e\'cntual si :r' itltor' lrcr.vi cll|rri{rtli. doclinn$al,e vestibuJaa'e, uncori bruta.le,sin1, lrirt lczirtttirrrrvli ' trr,nifestirils precum Di plin r:dtlm consccut,ivtlot'cgliirilol cirrrrrlrrlolii l, co, rneningeale, lrrriferice intraiabilintice. Se realizcazzi astifel utl sintlronr tlirl coclrlco prin acufeno, hipoa'cuzic gi rna ifost,ili \,('sli' r'sl,ibular,care debuteazil lrrrlnre, Ilipoacuzia poate li uni- sau bilateralii, de tip percelllie,cu ovolu{,i,. lrrlrirlii,, orlrrli uneori pini la sulditate (uneori definitivl, all;oorit'oversibili, (.r vindecarea infecliei urliene). Scmnele vesl,ibulare se tr:ltluc pritt ulizc r rutiginoase (uneori foarte violente), nistag lxs, tulburri,ri rlo cchilibru 6i hipoexcitabiliiate vestibulard. c) N earita cockleo-aestibul0ii zonatoasd, (hcrpes zostcr) csto [oir,r1,(' r':r,rii ln forma acutii, veltijuJ apa,re brusc, ltr crize, oda,1,[cu il,1)l,t'it,ir, rrr[ptiei, in contextul scmiologic al unui Findrom vestibular aru)()]rioH, rrrr duratii de 3*8 zile. Se poate asocia o hipoacuzie do pcrccpl,io, rldrli{cir, ,,r'olutiv5,rpinii la suralitate totali, $i definitivS. Unoori, instr, sinrlronrrrl moderate,pc prinl plan sil,utudrr-sc vrlstibular estefoalttl discret, cu ame.feli rllt]o simptomc ale herpcsului zost'er cefalic' dJ Sdndromul l,ui, V ogt-I{oy unagi, vorosimil dc originr: virol,icri, tsrrr,ilr,z6, I ncvritl'i, oochlco-vostibularli, (cu sualitate qi crizc verl,igiJlol,so), uvoit[ l)ilatoreltr, vitiligo' rrloleoio 5i polioztr. l,u,t Il arada, fourtc ril,r, tot tle la,tuni virol;icl, ol[.rr a\ Sind,romuL t,Bomlun[totcu I)t'$ft{loltl,ul,rntxliittd ilt plus qi dt)t{lillirr:(lo r(11,i}rI. .lr'ritlll (l(! l'rt't:vtrttl.o irr rrnck' f[ri, sn I\ Ilteninllo-net.nt-hrtrcnlrnalt, llltr, ct'l ttttt'itttlt'uoll, ttxttcirtl tr.rrrltr0 ou lczhrrri TLin Slnthom ooohloo-vrtt'l,il)l rlrlltinlo do rrorvi ofttolortl El ou Sotnllotlc polirmlicttlotrcvlil[ 1,tloroa, orr sinrlrrirrr liolridiuu do lln Oullll,ln'ltu'r'r{.

vcrl,i.iul vcrl,i.iul vertiiul ino vertijul inotitor.ilor.Ultimele slni, in roalitui ol,c,), rrl,c,), onlcl)t,i:rl, onlcl)1,i:rl, rlitrrlo, o. l',rlru.r,rrrl,i.ic. lil. ,,1,'ttlsol,o wrtija't sint amefeli in infelesul cei mai trannl gl

rlrllrrrrinnl; rlo unornaliilc rle retraclie(astigmatism, hipcrmetropie, mioflo miopio

cronica (trtritr rkrzrxrhililrrele hidro-clcctrolitico ou rc.pc[. s). N e,fritele_. cnsiulti cFl Dra lichidelor orralolilnfl,iooqi prin hemoragiilolabirirrtice)lxlt rri rlrrl,trllrine crize vertiginoase, urroori de tip rndnidriforrn. lt) llt,iirile. alergice.prodttc, adesea $i leziuni ale urechii intcrno, cU rtislrtrol,ii labirirrtice qi m:r,nifesti,rivertiginoase (Williams, 1056, oilnt rL' 1!likr;oscu, 1978). ll) It'orme particulara d,eaertij labirintic. Este bine cunoscut faptul ol ir rrlirltl, do procescle patologice amintite anterior, mai existl o selie tlo rrorrrlifii specia,le,caro favodzeaz5, aparilia ulor crize vertiginoase I t\') l'ertijul _f,&roMsticd,in ,,rdul d,ema,re1' se traduce printr-o simpto. rrrrl okrgio complex5,,dominatii, tle vertij cu alur5,paroxisticd qi tle feno one rlrrrrovcgctative (grea!i,, . vd,rsd,turi,- paloare, lipotimii, midriazii eto.). " senzalii de instabilitate, Yr,r.1;i.jrr1 eorrstii, in sau d.e riisturnare (rotatiol lorrsr'r'tt.ivc tangajului produs pe marea rgilaLi.. Aparjtia crizelor'rlo lrrll,i,j rlirr ri,ul de mare a fost cxplicatii prin fenomene hidrodirramicodo rlr'lrlrrsrutrlrruta,Li a lichidului eldolimfiltic, aare tuctiolteazi,asupra ftl)fl. nrt,rrlrri otolitic. Yertijul din riul t1c mare se insole;te qi de hipotonsiur0 rr.r'lrrlirr,li, grelruli, vtirsiituri, hipersalivahie,._diaree gi transpirafii rcci 6l rir, oJricoi oodeazil, dupii, inceiarea excita!iilox de cilLtorie. b) ll utij,al. d,!,n,,rd,u] de at:ionl'apare ca ;i riiul rle mare, la acoloir,rll lrrl,r,grliirlo indivizi $ensibili,traducindu-seprin vertij pr,roxistic sill.glrlr, (,tl itlte semnevestibulare.In cazul zborului cu ayionul mai DotJ sir,tr lriooill,i; rrll'rrt,rrurrrroli scnza&ii bru$te de vertij, insolite de durere :r,uriculu,t rl, irrl,r,rr|ri prin rl,ero-otit5, la indivizii cu ryirlLrsrr|tlitato uni- sau bilateralS,, (l?iquet qi Piquet, 1965, citati de Stoica, 19?B). rrrirrl lllrirr IInilit1,('ral ,4tkt. I'J.. d.e.. Dertij ,.labirintic:. vertijul de ascensor, vert,ijrrl .lo'tna .

rrpiloltsio I o) llrlsolo vcrtijo ds origine psihici, (indeosebi din std,rile fobice): r[)..1)r.r,l,solo vertij_e do carzd, oculnrl din tllburii,rile do rofraofie, in unolo grulrrJizii u,lo rnuqchilor'oculari, la, indivizii cale poartl lontilo ncC0l0l. prrrrzrl l,orlruviciului ds rcfrlc{,ie q,a.); vortijo dupii hiperventilalie ; c) I'u,lstrkr f) tu,lsrrlevorti;ic prin tulburriri de statici, (a,st,ilzo-a,bnz ice - ln tftboa, ttr l,ulbtrrll,rilctlo <:oordonaro de natur5, cersboloa,sii):

l u yi ttl ,t t lt t i : rr,) fir,lttr:lo (boala Arla,ln-Stokotr, _voltije de. origine c:i,rdio-vasculari, I rn tl i u tt ' t liilo sinuzale, aritmiile, tahicardiile, stenozcloaortict, eic.): b) l'llst*r vr*tije din unele sti,ri prodrornalcale anumitor crizo d0

g) faholo vortijo (lin st5,rilo hipoglicemico{i din hipomeflocbivitatol (l'opovioiutii colab,,1.978; Popoviciugi Pasou, sinocrrrotidifl,nli, 1081). rt ila orillina wstibulatlt (d,in tind,roq, 2.8,i,2, Munfeak\riIt oarl,'i 11iru'a'x molo rotrolahrinlin| ) B\nl:'pro(luse (lc sufsrin|iaugfvIlrrl yostibul&r,rl0 (thoot[, (prlntr-un prooottdo norritifi stlu do notuolr&tlo), .lioilrlI root{, [06

107

,r{. ri,,,r,,,.i,,,2:, ,ri,, i,i.* ,;,i,,illill,,,l,,,i;il:il;il,il'l,i;,]]li;ll,,ll,l);.j,,;i1ii,,,,; li ) ,\ t,u t.t\)(liilr


,n,,,r,.r:,, ,.(r,, , t', ;,.,,;;;,;,i,,.:',iq,:ilil:],,]:lil.,Ill,^u;;.;1,' .,,.,,,,:, '':1,,
,sice,r,er,er,j'. ,r"',1'i"i,itin :ll:,,;,',:i'l","t"""lli,rti;_r,i1i,".9*tbul;Lr ,iiiri;,l,\

rxr iirllriri''iiri ;.li.r'r l' rir;ii';illi'lrt*i,ll,,i*-r:, tilf,"li''j.

r ( : t lil

z,:rri,, rrr, r,,rj^:, i*p"t d"*,1.i.11;::li:"[Jill iit;l :,;illi:l;,;l,n:l.

din unhrtoiditrtr ttr unohi n.,,,t,(tt,i),t,,\ ,t,tl , ,,,,1,,i,,,"1i,1",,0''r':t',:,'ii,:i:

*t'i.ifr.lllJ pie'os,,.oar iz,, , l;i, llllllruj'*i ;,f;#4;:.,*ri"''# ,,,r,,i,, ii,,,i,jii'";,;,:;;i;.'r;;';i',lfr'H;,ii:,";li.iti::.1ll,1.iJj"::-'iogic:1,,r


,,ebtibt,t.,,,,, '!',,f ,ii.y:.'yy1';,i i;iii,lil',11,,'ff:;:{f;iii',,ii*i,i u;i !lil,l,!:,0{;,,,"u', (I tlDt()r'i, llrt)(,(,s.,rL |glr ngj, ai; 1. ,
.j r

fii-{ r ;;;rr r,;rl',l,lll', r Jil#3;[*i #"r#hfif:f i:.#'tl#!'{i11ifu """"i;'i'li;i;;l;i:l';llfj:,ili*",precizate ci,rai.lliiii,f larse'ri;: illi,ii: #":ft ;,,'lil',lii llt;;,;;*;lll;;;,irij#t#l,i#il""ii'l_;il","#1,ffi
,r.:rr r.,..). r,,,,r,.,,,",,,,,Jtf l'lii]j.,ii' {;j}ffi,.'i[1;i$?,#1ilili
lr\r ti,rl{)1 , I orlil > r r lai. i.

., iii, i,,, ;;; ;irtii;,d;1;*:*i*|j{{,|"",iti:i,Li;ttr1 iii:,l ili*i "'i,gi,

:r i i;r r ;, ; , r i, lr ir t1t;hfr i, r, rr i ii ; *ifr:iitilfl,'iiffi;l "ir j'i1,"Jii;l,1ll; ';:l; ll;l;;l ,li:l,i;l;l;:",,,;nllfl1ijf,illiiili;ll,..,iili"'J'l,il'1i?;ll,T;


,) 11, ji(rlifolicc.

lllfiif,ril,li , ,,, ,"i,i,'l,i"ii,'i",fii, ,,, ii,:i:,iili:{L:,,!",,i{,'!,,,ii,j,i,i)1,1;1ui,,, i;;;;"-;;i iuror zir,, : ,i


l:,;,;,1'l:,',,',li,l', 3i,.1yt,.1111i,r,, ll;,,:i'i;1,,?:';,f -,Li','*..

ill tIt' Ii'tt ttII t It IIi, prrlr1t'lii'liltsllt;;r'rr' rlrt ltttlu rlr, oti,:ittrrotrrtilltliistrrtzrt'l violclrt,. Ioillto ilr". rr.isl,ii,rrr lrr tttt rristtlgtnus r'r'i rlislilrglrrrrsrtl io itrt'ihrirrL ,,, Drrcii itL sintlromui-vestibular lierift-T ttisLrg .ctrirltlii' vestibulirl de ollgilitl r,rrrrla,i -si/sau lotator, in sindromrd ,rrs.] isi,c atlesea,,schimbltor de sens" (a'dici,bate in m:ri r'ulttr tlit'rrrl'ii) ri. i:, Irlus, aparc nlstagmusul Yertical, care nu so intilncfjlo IrirIiotiIt'iiiitr r llr iiele perifericc. i, irr sindrom'l vesl,ibularcentral, directia cilderii corptllLti[it' lrr.lrir ii{,}rrl)its rlr cste influentlti de schimbirile de pozi!,ie trlo (r:l'luLli r ?"n aceste sirrrlroiuile centra'lo se pot remarca nodilicr-lti It i IIt'I t' I'i rI i I lt')' t:r, ;,i',1iek.instrumentale ltic hipoexcitabiliiate, fio hipere\oitllbilil'rt itti'ilrrrrlll so con'strt'tti pl5'ti, in aproape in ca;re ii'r in scleroz:r' trcmplt '' ,, lripr:rc-r:citabilitate lt toa'te probele. cu grea!'irsi vr'1'l'rii'l'ttti' doar nturile crize aerliginoase 1ti Ne dentteazii, ('irr('liot li Incori intitnito qi in unete vertije centralet.ca de pild'-l'irr ritr <llolr-r:ielevasoulare bu.lbo-pnntine (Wa1lenberg, Geli, R:rynond 1k'r'jlrrrl (lt! r (:t,-.tan-Chenais ), in scleroza in plxci (uneori)r in lrnolc cllfi)ftllil(r tttlt'trr, in nneLettrmori de fosit'posttrt tIrirLr,iiicerebral, in sii'ingnbulbiesi 'serniologicapare q:io hiport'cuzitr (p|irr r,lrri ill{,s aturci'cind" in contextul (jr]1rl:lrzii poi pf{:}te' lt[ carc situaJ,ii lr.zirili ,isocialeak-.tncleilor cochleari), , ri . rdroamele vcstib'da,re periferice. i, in sindroanele veslibular:ecentrale reactiile nistilgnrki{),,itt rl'rttr' 1969; liiser, 1952)' -{stlel, itt trrtztrl qi co1ab., l,rri',i:'sintraie (Oarvthornc r,1,",'lirriituturor nucleilor r;l)stibulari, nistagmrlsnl baie in trtrti ttrttilr' mrclci lrtrrrrcrr' ,lirll:rii. c1a,r krziulea ueciom:inanti a rluia djntre :rccqNi hi silrrrr{'irrrtr t'li}eo!,ie' anuniti, pretlomine intr-o st' , ',',''il-ititirgi"iisul ln singrr nutdtlll vestibultlr, pui,cm intiltti llli llislirsrrrrrrl r'r,i,ste :r{e"ctat ttrt ttirl'rtt1 ,,,r Ir)rnlil p'.r;'". Astfef lezitnea lucleLrlui lui ]leit'ers 1tt'ottircu IllslirlllrrrrI 11ll dteu]lill:i rru.r o|izontelr ia.l o lcziune bulbo-ponl,inl \ (.ii ir:11 st.x predominant, reriical, Cintl lezirurilc irilotesc'ilzi cotttisttlrt' prt;;I t' lol't|1r Lr"t' I i(,i r ir-,se p-ot itttilt-ti dii.erso tipuri de nistagmus, t1:rt prcilttrtrir rr I rirlrnltul vortical. ;) E:{isten{,a,leziunilor t*,ltibol^t" oerltralc osl,t' lti'st:Llri fi Irlirr risiagmusului p,:ldulai, c:l.lc nn sil itLtiltrttlie tricirlrlltlli iit lczirr 1'',,tilr,1;1
)lt'0t'me eti{)'pa,logex.icetle manifcsNd"ri t:etliltittotse ae]tLrttl0: l'tt'Liir.tl' cr:rtltt.rl rerl'igittoasa tle ori,gittt: lxn n'ttlit:ti' /) I'arotisnt:h dc tlt-rsigutatriit, in trit:;tiirti'ttrll' tri .,r.r'lilr iu ttrtr;i.rl;ic constl -ssrl"ratir.t , r t r l 'l l u l r r i . {) r l tr i tr a l i ,i tr r l r l i l ,l {,t i r vo l ti j r tl L ti n r ti r l i i 't'i l i r tr t L l l r ttttttr tl i r r ( ) 1 ;i 'r 'r ( 1 l l ' l l ) 'r ':l l , , , r : i '. r i n l i l s r l scr tzl l r i i l r .l tl i r r :t l l r l i i ' .'r iti c i o tr ti i ( ''\tr r u .r i ;i tn i l tr i l l r ';t'i ti \'r ]l i 'i i l i r r o i r 'r r ' l l i r l l i {- l o t : i t : u .t [ ') to ,ti u r tt!r tr ..i ttn l i tt sr : p o l i l r l i l l ti r 'r , ) l L r ( 1 l t {x ) l i fr i l l r , vttl i ,i tr ) , tl l tti r r l .i t$ tl L l t i i r tr - o l l r ttz:tl i . l l tr i tt'si q tttr tl r l l r i l i fl 'r ) .l l i i i r r l ) r r r ''l i .i r l l r r r r r L c t s , l t s . r i i ti i i r tt .r 'l l i l r '', 1 t'IIII;ti :i i ''i 'i i l ttl tl r r , i ttl i l tti ttr l t r l l 'i l l tr i r l i r q r tl tl s {l t' !'r ) fi l i r " r , , , t i r ', t : r 't 'o ti ', , l r t'r l r r /r tti i Vl r 'l i .i tl l d t r tti r l i n t t]l t"tti i r ;l d tt, : ! ) l / r : r l i i t tl |) ||tt) ti ||i i || ( ) I) l i l i !r Ij r '( 'r r r l l l ,i i i tr r l i l 'r 'tst'l r r 't1 ' r 'l l .r 'i l l ,'l r l i r , r r i r l tr r i . t r i , ltr i i ti l i r t i r I' r i ( . i l ri i rt I i (, i i ' I , I ri l .i |r ti i ,l r ,ti t' l r "t l l 'l r t o l r l tl r i l :ttr r i ti I0 t ttti Ir 'tr IIt. , , r , ', i , , , t t r r , l l l r i r L i ,r 'i l r ,l ttt l r l l l tl i .l L l r r i :l i r r r r l r r l i {i i l l ttt r :ttc l tl r r ttr ', l r : r i i j r r l r r u r t l l l tttl l l l l l l r tl i I I ) | |( I( )| | | | I't ' I I I' r l ( r 'i l {l '/:l l l l l ( l \l l l r r i l r l t ; l r 'r t i i r r z i l r l i ttr r r t tr l l l l :r l ) L ti i l i l l l r l r l tl l r ';r l 1 i l l tl r r r l l l r r ) l r 'l i r l l l l l l l f l i ,l r tr tr l l tti i ,r l l l l ,l l r l l , 1 , , : r i , r , . , , l t r , r l ,l | t r i r 'r r r 0 l :r r '1 ,'r 'i :r l |r 'l , . r r , i r l rr rr, r, rI rI I r I , I r L tr l !r '1 ,.r \ r 'tl l ,{'1 . r 'r r l r .1 'r r r r l tl , ' '

, , ,1ll,l:.iil,l,lii,::,;i'j;i:,:li;iJlli,i;i,;;i,,i,lli,'i,;ii,l,iiiillil,li,,i,,T;;t,j,i:;1,,,1
,iroii,i, ,,,iiil..'l;-iiil;l;i,:':lJi,,i:,il;il;lillll:;,;l;j;llll; i j ,,1: ,,..{,\..
: l l frl l tt r ' r r r r llr lr r l rrrrrri s i 4 rl trrr,i t,t.,tl i b ttl (t,t.i r.,,r,,,,r,i ;,i .'

1i;i;;i;'.;i;;ii; o(,,1,,,,rr,o,,r,\ ill l;11';ll;;,'r,:'",,1;lt;ilil,ilifl,r,iv,,srir,rri,rr1.

lrrl l rrl r\lr ( ir l 1r . ir r I r r ' ,rIrr.Ir' i rrrrI' rIrrrr.rrI:rIrr li .f,,,:,.,i i j ' r,rri rtri i rr l0 l t

,lt;;;t:r ii;;,:il,,iii,,llil,l,l,llil:li:,i,lilil,,lil,:t;i:,'lll;,:;i;,,tl,l,il;i,,tijlii'l;"1i;iil,il ,,,,,r11),,1i,,'ljli;;,'l;l;1';;ll,,lllllt',1'l',;j,ll;iiiljlili;,ilt;,,ii;ll,",Jt,lll;;1,;';ill,,i;;,liij


i rr l i rrrl .,rrr' l t{)11
,,1&,1

lr.lr'..l'r,ziLur.. (l''1r' vi.irr r,,i ..lrrtr., llt;lt, ll)??, Jl)l{0; }1r1xrvi.irr ri l,ir,s.rr, '8tl :i) )t sir'inltltbulbia )llil,l|il!,81,!iIij(r \ or,l,ig,irorso sc plitrsoirrzi! trrllrn.! " irri,r' sirrrpl,'rncloinitialc, pulirr<l ,,pii,rtlt, 1rr Jic'in crize foail,o vi'l*nlr, iri. rr r,i,lL(,ulr llur ufoalc, aproapc ioldcartrra accentuate la schirlbiirilrr dt t,dr rr' :[I, (.1]pllrur $r asoclat(.cu julbuliri de ec]ilibrr. I ) I )t lt ttconertarfte tulbu{rile vestibu,lare apar in pesi;e 90}i, rlirr ,rrzrrri, rrrilnilrlstindu-se sub forrua unor crize vertiginoasg cu ahuri'rnttrrillilirlrrril, i!.speciai in cursul.py.seulilorevojhtive -ale sclerozeiruultiplc, ,.1:"r',rrrrr.l,ri ,.Liar ca sjmplo.nle.inilialo. Crizejcviolenic. br.u1rt,., sj;,i rrLrr,. \ | ,rr,,t rl l IISII | DUitlora[,de ojJjcei olizottal;i schimbilrr1'rlo.oUs, '.Stc. rIi|| |rIrr.r)||si 1(,.t1(.,1 stu |otalor. inso{i1dc l ulburiri dc ocbiljbrrr.Ur:cot,j, rlrrl.r,itr'irruci par.eze cie ooulomotor citern, putern constata un rljrior.iit,lt rtoltriculat, 'istagrirni ,..ltgc. oetu|lelc sp_itao-eerebeloase pierra_Xlarte, L]t, boale lxti, ,, ,f.) ,l I t u\t! t, rh .:t di.', rstlcJut'nede altoJii cerebeloctsr puD apjrca accc,.^ Teiti_ ,1.n . t |.clorl-tntc.clt duraLc dc la {.itora minutc la citcr i.i,zilt., ''r):r,\{' Iini ir,rioqlriLlo olt ttaxie ccrebeloasii,D-icu nistagmus, cao", -,1" obicei, eiito oril ,,trl:-1, l,ib.{r.r',ri ii lcnt, pctbisijnd si inrie g,izelc icrtisiuoo-i. p,ot , i|l',r'r{ { .,.1 Ioirtu] li sitrl rornl{l,le,.dar "t,, de mu_lic ot.i ilrala J hilrer|xcifabili_ lrLl(1, l)ll,ild fi:u.nizaohiar unple indicat. cle diagnostic prec6aela adtli,ii lrr('r i r ir'('sirn],tiomai,ici din familia rerfiectivi (Fh cox'si L"i*tl -igil;i. ti .4l cr:tiurtite aentriculului at ly_tca qglio'arne'qi .[i"t*i ) . *ri.l.*ii r.r rlc vcrl,r'icul IV, glioame de trunchi cerebral,,alte tumorl buibo-pontiitcj iilr rrrri( )(i'iiri tr,pt'oape totdea.unade tulburi,ri cleechilibru, nirtagmu s d'izont,o: : rt;r,lot \ \'i.tsiiLuli, semneCn!.pbcloase, divcrsei*Lnnc de tlirr_rrLi ',rli(,irl, ,<i ,' rr.,)rrlr, ,.(r(.||]f'ol,rlar, ]si n]alifegtet,i vertiginoaSe il] c,lize, tle obicei rL (,|ii,r|,lI|L{) si acccnl,uatede sclimbiriJe de p6zilie ale r'\ i(l('rtiii,hir,u- st:,' i'excitabiritatevestibulird t'" p""t capului. Se I;rritt rrl u rrcoli JriJxtacrtzie. "r.'i".i"""i"ilt,ir", I'rrr.rrritrlr ax1;ansive vel.Tiene qi rle ventric'l al lv-lea p'ezi'tii cel rruri lqflr;r,1, irr contcxtul clinic 6i iindrom,ut lui Bruns, arr" ,tin i. y,l1 ""osti dc crifatcc qi vir.Jtult, '1.' 1]ll::l::l.i;.1

do lltt'cllttrr ,L'('li!l('{,, ir,i\ir(,11i(:, Bljxlcsltl}lilluil:i,rii, tlo cokr rnlli rtttl{;tlttf i, sotrttttr ru rlclvilor octtlomotori, ott rliplolritr. tti i,ri,.lorn. (aI .lui .!'iytlty ), tlr'ii td'ittlttgitr c) B'inrlromut Ttseutlontti r,r..tz*tii. se c*ractdrizc:lzrr, t,r'irr inanitcit;rri ver"liginoascirrst*lrl'r' rru'irl, il,r,, :m,i nrrtin brul,al decib-in boala Mdn.idre. S1 VeitlSul paroai'sti'cepiteptia,. tr'orna cea mxi pctent:r' do vtrrli.i psihoselttoritt'l .ii lraroxlsiic epil'epnii este repr6zedtat:a de criaa tampo,ali' (Arseni ii colab" 1978; Grsl':uttl' .er :aiie lle ineleal,i 3i-rostogolire ",t, r:r;r r -vd"iijo1 F6Joviciu ri colab., 1976i Stoica' 1978; Popoviciu \siPascu' l(lii{)'

{ie '. urrrt j octr cll eploEetrtreoseuitde adtivl, fie in mod rellex, sub itrllttctt(rt 'o.siibulrtu, care realizeaza cxacerbrrea paroxislicl :r .i,'nr """it*iii l'ocaru-lui. lrestibutogatud' V erri.iwl' enitepl,r'c(epiteBsi'a ) poate fi cliferen{'iat tlo rrllo 'de 'vertij - cu ' aluri paroxistici, (Sloica 1969' 1978; S:t'gt't' torruc , lilicc . ,i . uirb., f'glO; Gastaut, I973; fopoviciu ii colab" 1976.;.PrinciPrulcl'r de diattiostic diterpn!itl, sint : a) alterarca cunotIin{er i o) 1l'Fr'r'rlrrr' 'i:tite;ir (Iie-independent,fie altermndcu alte siulptomc cliticc (lo ('l'r rcrLiiului i,';"'";;d;rH,-tie ci si buli, in cadrul unei crize epileptice convulsiv. i g'*o.triizat"l : it couslabareaanolraliilor EEG pr'rorist ilr',r'pi ., ''ul* lclrtice cu* loealizars ieinporalS,. Traseele EIQ po! prezent'a' dt':Lll'lr'l' iol'rue iritative cu sediu temporal qi in perioaclele intercritice' 9. Exi.std, insX gi oerlije tenporale ne.eltileptice(in tumori, .altct'tit" l.r'rLum*iiJme de lob ternpor6,I), caie apar in crize cu durati mai ltlttgii' rlrr rliteori sint aproape lerminente qi-au ulele-caractere clinioc pit'rl'itrtt' sau dc loltot il'r'' t,r,rle. Astfel, bolnaivii idcedrci, senzalii .le ghalie, alorid.ica,re sau nu (L(! irrrllr inso.lite pianuri ale spaliu1ui' proiectie in diferitele rlu rle r,,nolCiostaut, 19?3; Popoviciu qi colab., 19?6; Popoviciu $i Pascu' l1)$o; | 9E1).

ii,,'r

.lueptic {,oatoil apgl

(in cazulcxisl'r'tr1r'i .sponran

mt.nti rrrl ,:r.1,rrl rrrr,,trit oda{I cri coipul 1in.,,-60""* 1i I rrrisc{ i"i.,,lt"i_ r r,r,lr, ). ".,lil"ii-..ii"i 7) Nut,rnnitatestibulard(Dr1 Hallpi,le, 1962 Cawthorne colftb., ; $ $i (.I| , ISZg)cuprinde llrt;1,; l\I i I' |.,r'ri B forme tlinice : uas,t[bulurd p^ro1triu.-.zi.sd esteo afecl,iuno benignl, cri inoi" , ..,::!,.\'::::,,,:!ta , (30-5qde_ani), careinterescaidneuronifvestibular.i, lji. ".t I Ll iii!l]9 i$ulte Debureazi,brusc prin crize vertiginoasocri ::l: :l.ilill' 1ll;lll.! $r i.cr-qenr4,. rr('||s|| t"lr,rr. in citcva ore sauzile,ciup' carcdisparc.-Nu Irrogrcslvir luting0 rri. irxIrr, I r'i,irl,onsitatea crizelor Mdniire, dar qr6bek (ir..i;;T; ( l'l,N l) .virltrnli*zii, ".*tii;6;; de sindrom veslribur'ar cu-rripoexcitibitiitate lar1,*r rtli rrrllr,l,tl. 'n

-!r,t..,,posrurat",.r-iolcLrtfinsorir I rr :L l 'i r . r ' r lr ,t.ir , j( . hlm l )j i r' l c d o p o z i i i c A l e c a p uIU i . B ol na.i ,,ul i ;i

NIIRVULUI IN PATOINGIA DE DIAGNOSTIC 2.f)..PROBLtsMI] GLOSOFARINGIAN

rertigittoasd, satt tsr.rlijulrpidentic(Cirxthurne 5i r.,rlrr,lr., _ . l,)- -ryr'i'r"a,r'ila llll;1,; N ir.ls,.rr cil.t(i rirr lVil,r;,1scu,'lC?g) ;i .rrlrLb., lt,joro t.,,s,., irrl,ir'i,ii "',i;,Ji"r:itrto$ti.?! r';rin.rl irrrir'{i's .rr rulrru'irri r','spi.ati,r.ii t(, Fi .' iili",i ,r||||rr'rrIr|(' rrrtrr( r'rIr'r'fr|Iili.r'. T'ru't.r'ific o irrfcr'{,ic vir,tic,ir,lilrill(r s,i:"ir ri rlrr lrlrri.i'1'rzrr, li.hirrilnli, rim{ooita'ri,,aqa ir,,it'in"t-.i.,"i.rr',,at ;i rr,i rrr l'rtrIrrrr.rrcr.l:uIiIr. (l)rrr nl, T\rnoviliu ruilrll., I{rCf llifur'tiir,sr,u ; .5i ryir,olllr., lrr{lir).'l!r,lrt.rl r'riri( (').hri'rrr rr:urriii'r*li.ritl.ir;li',i,,in,,,-!i,i:rullr, r;.ir.nitrrri, I t0

ilnlrlicri': 2.9.1. Invcstigaria semiologiei a nervului glosofaringian i.ei motorii.: Se celcetcazti'motilitatca ptrrcLt'ltti a\ Entrnenwl fwnc! r,,,tt.r1io" al tr,rinfetui, tlcglutilia pentru Folitle' cYcntuala plczettfi a' .r rnuLtluicoltiuci tl lui Ycrncf. It\ Itrnu'menulfitnalict sanzitiar, &nalizind scn$ibilittte:r' ltorr:ltrltti tl flrirrg,lrri ;i ir,tlrjiLrr llnrigd:llicnc' t,onl.rriLr ttr:n:nrialoconstii,irr investig&ii1l' t:,\ lil,t;urnr:rt'rt'L .glsl'ulrti.ltt .[tr'na!iei, 1o r:litrinl't)' (tltt , s,iu(riol'u.i,, lrttltr,sobi lim5ii ,r, t,,,i,nu.'i li rsii'.i,'.r,r'il nrtt't'!irri irl ltltrct'it'tr':t l)ltroi'jtlt\ ultetdirir ('(,trHl,i-t
t,t,t'[n,llttrlu {\\ lt){.tuLu turingirvte.
ll I

i\ l': \t unul. Iunoliri grtBl,l!l,rvr. sitliv$rlrr{'K{'ilitlllr qi rr rr.llr.xttlrri ,1lriIo ,r:r,rr hiIr.rrrr.ri.li''ilulivrtr';1)

pr^ r'rissIrthilc,,sl,o lli:rgllrsi'icrrl !.lf.i!. Novrrrllliuglosolttritrl;irrrrri. .st cLlture: itt ltttr,lir' (l(' {'clc /rrl Jt']'ttt( 1(,lrf1[ ullot' l)rlr'l,iotllllritlilir attii lt t'i.ttl,i,tirii satr, Ttrint.ard (est'rl'ilr'lii ilt l) Nnrrutgia glosoJu'in11i I r,r'rn irr.rlogia riecbi teime,n care f'olluie abandonat) afecteazd ill go]ll'rtr,l lrrrlrrrvii peste 40 tte ani. putind insi Bli apar5' ;i la tineri. t)('l)nlnl bolii cste de cele mai mdte ori brutal, iu llini, siililtal'o rrllrrrrrlir. lntre prima crizd' durcroas5, si -urmi,to-al:ea pot trece cittvll r:itrlirrritrisau cifcva 1uni, perioacli,va'riintl mult de la caz la caz. Criztilrr rnnilorr(f rlevin din ce in ce mai flecvente. l)llr'rror debuterzd brusc, violent, la baza limbii sau intr-o zonii' ditt l,,irr rrnristhlia tii. Locnl durerii maximale se afli' in regiu:reafarirgiarl iii "inelr-ati, rle nervnl glosofaringian' I)nrexea qi zonele e tlo lrrigrrrrli "s:i ilrrrli.r'o sint sl,rict localiza;teuDilatelal (Arsenl fi Oprescu.1979; Dcptui$ stahilit klcalizalerr (1963,citat de Arseni $i Oprescu'1979).a | 1l{;8). I,l'i{rl(son lir' in funclie de {or:ma clinici: a) in forma tlctsir:d': rlrrr,'iii irr lrd. ,o1u?, spre.timpan' ruri"ljlll lrrzrr lirrrbii, in regiunea arnigda,liani, cu iraclieri^ in regiuncit' rrrrrrrrlilrrrlrt 6i lggiunca submarilar5:t:J ln.forma fat'.i,ngianii: rrliirl(l,rliirnrj,'" r) \tt fonnu ti.mpanicii satt' oti.cd: in rcgiunc'a awicrrlari' prolurr(lil, s:ru nr condlictul lutlitiv exte.rn; d) in marile ytatotisme il''trcreu' t1e ccltl ir';rrlinsj .in zotre m:ri iltinsc, respectiY rlai inferioaro fa'tlii' rr,,rrl,r' dlrroreil hel'eaz5' i,.lrrlrrlc ttrai ils (Arseni li Oprescr, 19?9)' Bolnavii '"1i( ile violeirtS,'5i de ahoce, lscmuilrl-o cu o ,,lolitlr:ii clo ,.rr j'iiirl tk'oseLtit devtlic" etc. In rare sit a;lii, durerea estc apreciatii ca o |rrlil,". .^rtrrsoc 'rlist'onfot t (BoJrm qi Strang, 1962 ; -Bues, 196ts, ,, riz,,ii,. ,[,, ,cit'a;li dtr - bolii de 20*il0 debttul ()l)r{rsctl, la csie unei orize l9?9). Durata ili '\r'rr,rii cltrerli cst'tr lncetarca bolii. rlrlr-se nrilol1,t odat5, cu cvolntia ',',,,rrr,i,l, asitrifiilcl intelpl}loxist-ice intel']'aleJe ci, d ebul,ul si ort lrrl,rrlrl.ilrr l:t'tLft,ii de la uI boln:w I't'l ioliktle libcrtl intru crizeledu]eloascr-al'iez5, 1rIrrrrrirIitur. zilc. Roala!o:Il() orc s:l* Lliteva, 1a rhr lrr, cil,oi,rtItrirutte 1tini, citevil irr rrll,rrl, (ca;t llttl' dur:ite qi variabile oa remisiuni rlttltroastl ,,i,rlrri itr l,ttscttt'i :I|l||,1r, t)r,r;r lrr' I -i atLi). Clizclo apaT tlc cele m:ri multe ori ziull. cltt jn fazole alvinsa,te clizt'ltt 2llobolii De asentenea, ,1,'t,,'i,,'itirrs:isi tton,Dtc:t valinbil' de tjmp intervale la se relct,i iit slh't,, care ;r, lr.,i,r1r'ul)r "d.e neTralgie glosofaringianri presrlpinl0 corect filrthi.liIrtr ilittrtttotl'i,r:t,t.ltti' r.tjltLi in timpul unei crizor anlliza facl,orilorcaxedetermjllil' rrrrrLrlir',':r lrolrLri (,,trigger zones") (Arrrlrrrli{irrrlizci qi locatrizareizonelor declartqatoa,r'e qi 1981)' Pascu.r r,:rri si {}lrlcsctt,19?9;Popoviciu Illrriirirol), pacieirtului in timpul crizelor-permite ollscrvarea crisptirii i i iuloluntarc a miinii ta nivelul zonei inferioare t[ ltilei fi Ir,tr,i. rr,rrtrr'l:it ,rllr. l:r,r'illr.,, sa,u sDre urcche, intrerupexea masticaliei etc' Fenomcrl:lo homifotr'i fi pritr i se pot manift'stnpt in inroSirr':r l'lr r' ." r I ,,, ,rr,, ,t , ,ri i i :.i.rrt ' tlurerorlsc bohrnvji In tirnpul crizci partcadulolii. grrt'ii tlc rrscirciuncrr F,l,irr.(l(! rrbicei, olisltrti, cu fncit:s imobil ,si a'plccfl1iinainl;or pclltl'u ll snlivei. ln alte (iazrlrirbolnavul iqi montinc callul a'llooatt lrr,ililrr srrrrlg,r'cr sn,rt ili aptrtd, 01 mina' urochon nrtts.ttlllttra h 1;r'r'txrcrvicalli, rrr :r rrrlii.r:r, rrr,rri r'\1'\rl)' r':rttltlttl llll(li1:iv lurlitllrgtr,illl 1i/slrtt it.r',,grrntrl, cliz|lot rcfirozinlir'o (lllpilr Atrtlizit, frtol,ot'ilot'tln,trr Irr'cipil,i! ttprtt'i{'irr glono tgiitnt'[. lilt't'it tttttli lrrrlnltv(ilt llr'vtillgi{r trLcnl srrlorrtrrtitttilii it rxrt'l,tt,rr(i ltt tl HJrt'tri:t'l tlt'iztrlot', tl|!rllllnqltttrn' itt t"",, tttlottlrltl l)r,,rrlrrlilirr iorrlil tttt '',,, :rl{i Irrolot'i ttrfii,.;'i,ttrtlrtlrr,rLrglttlifirri,r'risl'ii'rii r:ttl r,rl,l, ii,rti i,l,'1,1" Dr',',t 1tt"'rri lt:rsrtltti, rrttIlrtl'ttl ltlsrrrt' criz,'l,rl: rriitrrr:ti'ttli,Hl'riitlttl,ttl, , trr,,Ir',',ipil,t rtprrtr(irr ,16

t'ttrtvrttt r'i.rrrrtlir r'i..carr':r,il,ll."i,,;,.!;,''i1.,i:ill,";,i;1.],';.'.""' rl,.s,.hirtr.r,r.,r srr'ir.

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'S:ll*:ii);*,""r1,-q,e:Ld,";';?,,:?;.i ll;1i,T;"#!'::ffij'l;,.'"""" " motrorii salr gusia Ye' 1,irl,cr *T*{ft'"'?l#::tii';tll*'.i:ilr:!"i:l{'rinl;i"' jlr I rill;l l;;; ; ; lll lll'jil: ; ill :.' ll';:::'; :il" rl;ji::l;l -: l',, tr r r r tr r i i r 'r r l"i r "r r'' ' ' ;,;!:' .1, ,,r u',1,." ;i ;i .;' .i ur pc r ,i .. ,, r r ,bii

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,,ii|ItIJlii,'r ltilll,r,. Hltt(lt.rIrIluI (1 ()ItI t)I(,I,it, l)tll,r,ltoilir!v:t I,sl,(! l, rLt u l,tri_irr cltitr1(':t,Nir' .lr s:u(ii|nl.o vior(f r,r',rsrrr,rirrrirrri, (lu tl$urintiro novr'tlrgiL\ gl(]solr!tr rrlir:{irrrrr, t:rrigirr, \i, IoNllt'oIiv, li. bo s,:rnudc tliagnost,io cst0 1,,.itfll,lli rlr|| ,'r'(.. r,. punclul in_ lllrirrgrrlrri superior, adicd,intre ci}nu] car1,i.l)r'r.,vor.iitr-r, r:tjr rr' Lrn ( 1.[ fr osul l]roi.l. lloba rlccisivd este alcoolizarea nrvului, cr,r,o l'l||rl|rr rltllerca,. Uneori se constal,ti asocierea sindromului laringritri rrpcliur' ou sindromul cle ganglion sfenopalatin. I I ) Neuralgia glosofuringianii secund,ard(simptomatici) g]os.ofaringir,ni,s^eoundari, se d.eosebegte ctini,c d,e aea, primari, . .. rin :rL(,al'cte t ):.1.1..:l*l t'r' elemnnte:&) fond drrreros continuu,pe cale se supropull r.[rrrcroascpr,ro\isbice: Lr) tlurolqa, nrr at idqi - intcnsitateb, dctci ' Ii.i,r:r,rlr. ,||||.r,'\ l:llglll pnm rf lr : c) dulerca so .localizeazii aproaDctorclpaunaitr ,:.,, al. g-ibul i. crr iradieri r,uricutare si frr:r,ndibul*r.e; rt.1 1'11 lj^,pro.,ly-dc,,' ,.',lr\t:Lt,i ltipo- calr tnrstozi:l lojii.amigdaliencsi a rngiunii farlngie'n,.: r') r'ris1;i 5i semne de afectare lsociatd ii trunchi.tui dotor ar neryuru i rllosofrrliirgian; f) se a,sociaza qi semne din partea altor nervi cranicni rr\ ( r,rrrlr; g) sc constati, extindelea ariei durcrolse peste limitele anato, ,. j,;1l glooof*ringiao ; h ) evoturia cs[e progrfsivi, cu agrav:]r(,rr, " ,ll:.1I"]!i . | ' \.rrl,t.r.r''":li r':lpld:i r simplomat ologioi, fdri rcmisiuni. l |l ,.rrrrtiL unor lorrnp ll.ipice.si incompletclj, dcb t, sirnptoma{ ologirr, t,, t r:rlri' i glosOlalingipnC recundar.r' eSLe dc cele mai *r,Lt" OIj SuJiCir.llii rr| , ir'l ('1 :rcl lst,lCu.l\lUIf e tot me rlp nevralgie glOSOfa r.ingiani1 S{.Cundrui. prri irrsi rlcbuta cu tablou cJinic rle ncvraigie i;i" aceste motiv(! 1l;im;r;. 11rrrl)11'r.i tz.'t cii orice ,er'ralgic glosofaria-ngidnJ,irebuic consirlerati, rlo ll rr,,''( n,rmzri jo:]I.iilor 1.'rll .r drrpi efectuCrea in\.obI paraclinit,,. 1 lnlynrlar;,ri r '||) |,t' r'r.:t Ulnr l(.zUll.bc rteqaf i\ o o vom cOnSidr.r* pr.jmit,iv;, ('ttu,xclc acle mai ft ccvenJe aie rrcwalgiei gloso{aririgiene secun{larlr -pi';"; ilP t./r bazei.cto rtiulai liuai alei ,;1";" .i,' ..',::.1 .:.."\ .t"".':t:!j':"^:lJ !7lilt tll..(.'il,lr' b) tr&umdlismele cranienei c\ arahnoid,itele ,{,Un..r'rnolrflngc); cen:r)ttrt: () t(,tt,crce 7unrcti: meningioame, neurinoanie : e\ anel)tisme ulr\ |rr,r'rrIirIr,i (jl,lrunc i t) i,nfec,tiilocaie, indeosebi amigda,iie;e etc. I II ) N eualgiu glosofaringiand, ,,Junc!,ionald,, (simpatalgia) ,\r,r':r,stii, llormd, d.e ne\Tc,lgie glosofaringiani, se caracterizeazd, mirr rI rr!.r r cr rritt,totjercle arsur:i, 1.1 b:r,zalimbii si in regiulea ai, r,ir,rlr{.r,{' rll}ro trompa lui Eustachio, spre ur-echeafoedie, trUgq"ii*ei' oar Dl spre alto ( zrrr.r ir'o depii,qesc teritoriul nervuluiglosofaringian. Std,readd dii;;i;;i; -tilidi; :t,lr.ltrLvilrl r[r.viuomai prosnant:Lin-1ifrp-u] clegtilt,iliei-.. in Soi;'. l'lrr:r.rii :urrirrrprcsinunui"corp sir{in.'Din ,1;;;;;;; c,cesl,i n:}ci{!nt.i sl,lLsnlt' trltr-oglenc r,U LUSC. Ir|'r'rrrrrir rn ineerCxrilelor de a Climila l.co"nrit rri,r'riirr)'..fi.,za!ia

.l ) ' l ' utt,tt , , , t il" d, f ullulit i, 1t t t lit : 'lit l' r "'t r : 'li l rt ir' . \ r' rrrrrrrl t |l r r r 'r r t ir r lr r l |; r 't it t I ''I t I i lr llr 't liL'': l rrrrIr,,tl i tttl . l ' :r't : uljzi:r nr r . 'tiiir r lr r i lt it t r 'l t ir 'l'r t '111" i, i{ici 1rt'ttlltt rrolirli' llt' rtl-tlrrelrri f itrrli plimrLirti l,'t',lrtl5ar'lra ;ri dcsfiiquralicl"' ' ,,f',iiiii, a"id,,t.toasi poato'antr'"n1, lllil,iurr(l{ r('rt ruli.trtlttlrlttl' itr Lt'tittc'r" r,, ,l*r"t iezi'nilor b-ilaterale at nt'n t,hri glostrlu.i n gi lrr, l,ttllrtrtri''ilrr rl. t t lt t r ,1..:.l rrl i ti . si nl qr lr e. S- a sr 'm nal: ll. {Ll' asf ll! {'nc1, u lnot [ ili' it 't r ': t ' lit r t l't t lc culio t t 'zot t : ut r lr r \ ' ,,i o - . liii"r t n* aspeclului l: r 'tinqolui 1r 'r 'i ' ,i i i i ' i i ' i " B )P aruti ziat t i. uselt 'iuluicot lslt t r : t or super ior alJar it t gt t ht 'i'ilol; r 'r 't t t in: r ,r,.r' ri J' c, i al .r t l, - " a i: r , r ing't ui ] r Lt lt liz&1 , si'r ' 1'alior L sJnill. r r r 'r r f i l'r llir r A. nn\ 1. ( lnllI il) |l, l. c|\ {. I I J: '{''. |||||{'iI Z'I .' us \ / c] 'r clJ) . (sci l i nl ] coI t jU, i l, i ] ui 'r or t it elea hr in3' lr : i . r I lr lr : l ilr '1' Ja {onom clor . 'o" sl] ll 5i rr, r,r,tounti a , r a''

jiliotic:, comlrnsatorio,, ccl'r.l,lli rrrrrsrlri aiw*e repeiie p"in r it,lxrlil. siutt cslc cljrttilttt:ti' "i,J'-ii"ii de faiingiain partea paralizatrir f,ri,iirgi.ti. Rett-exui prrrr se cal1i(rleiiz{ilz'i A) Tulburririle de scttsibilitateli senzoriale r'tt litrrlrii, :r pc inge pe fri,r t,ipociiezie sau anesl,czie ;i Jre19c3 lonftlir'rt'ti lrifr slfl aSuc;io 1'cnrttl atner, in 5l'al'l{ \'l!lul Iirrrlli'l Pa,ralizii]cunilater'alcsau bilat(j]'aleizol:lte alc nttvltlui glosolru|itrllilttt ,,irrt'exceptioaale,ele in'riininc]xse rnai {r't'cvcnt inpletttri ('tr lrrrr':lliziirrl(' rrclvilor invccinai;i.

iN patoltttit,q NliRVlll',tll 2.10.PR0BL,EI|uDu IIIAGN0STIC PNI'UilOGAS1'RIC

irtrl)orlrltul; in intrerincrm clur.erlor.

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2.10.1. Invcstigelia serniologici a ltrvului vag (X) i[r}litrii': tll tttol'tli A) Dsanterutl futtclie.i ntotoriisomalirt:constil in exattritlnt lir'lrirlt')' (pcrrl rrr r ,tii vxJuilraiatufrli 6i i la:'ingelui,prcturn 5i a deglut'ilioi pozi(iru i Enanzeit'I sinlia : vilul palatr:Iui se elamineazii' aprcciitldtt clcttl'ttrt' 11N1slio a evcltu: 1i r,t,,i,"i.'"u.ttu"asi sirnetri*,r'iiulti, prccum ;i llo iriqc[r' inrl'oluntare velo-palaiile. trr'rl'ir Daamenul d'inantic: r'om {ace aprecit'1i*supla trrolilil'lilii ir:ult', (tt:r'' lroc:rlr' allurrito promrnl;c sir, r(J.Ltru care se cere bolna,vului '.'I('''')' licrnn, vi'luluir l[etr' ntin]irrildu,-sc l'c lil]ir)' ltr(tliit'rrii' ii."^A"t"t*lU, "i se remarci u asiuret.ie a *i'luTi, ttt .ttlr't irt'll' ri:t'tli trileziuni unilaterale plrtta sllrritoasi'. ln.1ill)lul (rxllttrillr'i'r'i cu ltctjar <1e ,fi,"iu"*, i-pr"u"I rlclt'r' ttlt tla iLsimcltici Lr'zittttilcIIiI:r'i.'tItIr' rtlnatt'i l.tct','nl s'r. sil'rrr "',,titlt;tii, inr'r''alil prr'1i, liind accsta i,iiiil'li iiirri"*" ,i nirr"tuiln ambelc
c()lI [Ta0tre. , ijliji' r r t : lt r lilit i. r ' D t.Ql U ti !t Ai; e r . lam ir r t r r , zlir lr lr d lr ollt ar t t lt t i sit l) ( 11,{'llr , l/ 'r. l l t tIr t t . : r , I iclt it lr 'lr r t . r r r il*1, , r 'r ul'. r ir , ( r l'Nl. ir li u i r. zir r ni ,t,.,ont,." l u l{'zl {l( 'lt lN( " l1l ( lr 'r 'liLlr \ iLt lt ': r ' l t lt nt i t ll 't r olr iLs , t llt 1t : ult r ', ', ,i ,rr i ri i r u.11,'. n, rl. 'l1l ( lin r uI llll do l) ii1t . u) r ( l, r t r r r ; r r I ir r lli ir - t r : uh|r . . {1lr ilr , , ,,i i i t,i Jri l at * r,,nt , rliohidr lit . lr jr l. lr r '. [ ) {r it s. r l( ''( r l, lr l ii{i. i , , iir r , , , ll, t . , sl il, . t i, , it , r r l r lcgir ,i ,,r,i 'Jr rrl) i'iril ( 'ii. llr 'lilr gt 'lt t t r t t st t lit licii t lr r ' t r r r r lt : r ' ,l ,,gi ,rt , iiit 'i, t t t '1'r 'r r 'l'rl! rl tt' i l ,i"rri f,r* ' r r r, Ii L ixnr 1nih,l,cl1tlil tL I : I r.' r',. I r, r.rr 1.ziur,r,' lrr r,rr,1xr.i, l i,'u,'niir, ir,?rr,,,i r,:ir,lirr i trr,tvtrl ti vl l g ( si, r r llilll , , t t t iit t r ir r i lt t i Ar lr t t r r ", r l. s. t ir t lr r 'Lt r l't t li, . il'it 'l' t lr r l ' ol rovi oi tt | ti | ! r , l| r r , l{lsl) .

i,l.9.ll.-Puralizia rrorvului glosoftringian I,,l,l'rrtizi|, nurvului uk,*"1:11_iilti,l.r= so l)rir: disfagioponNru itlitrtc[1,o ilo]irlo ; tr:lftlliziru rnr -m.r,nifesti1
t lil rbil, ;lt t.l

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l,lr r r r L tl i j i tfl l t.l r,l ,l l l tl ,t , . t ' i tt4 tltti tl )r,l l .; r i, r r ll||r |lr |ilr u ri ,s l ri t,;ri { | t.rr ,.r rr r,, l r.rrtl r ri ([o l ,l l s(,. l \, 1fu Jr| r,r,i zrr| r,:r r.r, i : ,,,rti c i i r r. rl n o,\i urron l l ,r.i l gi rt,rri ,,. i i r : ] , r ir r , r rr.L rri rru i rr,rrr ,: ']:l l l: ] : : i, l: lr r ilr . i' t , ) r .l t(,)ti ' .i { 1 , ,r,rl .l r()i (l i irol .i tert.i d, l 1ur,r, nuri 1i l .i r,r.r.i ;i l i l ,:,1 'z ir , r i' 'i ,. | 'rr: r lr ( . : r i' , . , . r i g u ti tr..u l rrri l rrl ;r r,:r1 ,i ,i ;; 1 l ] ti m!,uj r6rbi ri i , l ri r.r.rL.r.r.:r |,'.,r,|| , I I , |. . r t li. llr . . , , , n s fa l | l !rl u _ s e s i trrj l , rr.::r.ide respi rrrti ,,. l ,;rr:rl i zj i l r. ,l r. iIrirIIr(|L()|i pr.oduc modifici,t i accir.tlrte Oe tona,tic'lpiirl, ln ldorrir,), r.rr I rrir| | |r'rl r r(r lrln lralii. Palariziile dt'rbd.ctc'i realizcazi,' r:r.ir{ cont},i1,, dise,,i.t{l ,,1: I ') .t ( | I I t i I t I I lt i,lr l,r j1 t,i t1l lll 1ol 1r.l ,i i

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| | I . . , , t t , r t . t t tf t ,tn ,.t;,; i .{ 1 , tt \,1 .| n l )i u 1,rnr,i fl r.l r. i l ,.l rrl rri rtl oLri r. | , l r. ,l ts r' rtr: s i rr rl ro r In i l (.- \o (o,.ul or,:rrrl i ac. si l rorr,r.o j ,,,,], . , ' , , , , . . 1, l, , , *' , ' 1 ,'. , , l. ' . . 1, ' ! , " t - ; ' . 1 !i i to r u .e g e ' ,:' ;, (1,1trasi 4pn;i se). l n Iezi utti , , .1 l ttn , .ra g n te ,, ' , l .] i .., i rc n e o l ,,r..i . * i z e .,i e r r1;' 6gp ' ' 1" . ,l j .l :,gi .,r r hi ,.:irrl i ,.. ' r lr { '"' : 1 , '{,'."l , .j , , ,, , i r rl " p a * i l i z i a acut} , bi hter;h lr r r ur i z rr. rl t( " ti l l a l i ' 1 ,. l netyrrl rri , , , ; : , . 1: . o :i - i n c o _ rl p i l .i l ,i :- { .r,.i .j u r ,,. Ior rj ,l .on i u,:rrl .,.:zi .i ,.; ] , ll, ] ^

i r i n s p i ra fi c . ).ll,,n1,1,,ryt f.trnc!-iei 'se*zitite sornatice ce.ceteazti sensibilitat t,:r, ., .l| ', :| |.rr , r . lr r r , ( . t lL l r I m u (,o !.F ;u ,. a c | c s i L ri lo erpto:.l r.i . cl i ni ,.,,: z,,n;r

,,, ,.,.,,,j,i..I] ,rporrioletlrbrLriir:i i..pi""i"rii /in s1,,".i:rl :rt,, I :,'l1l :]u.i Tn parxliziile j , , l ] l ]ii,.ll; i u.r 'r r.il,o-eo.._ii-stridor.. ro t rlo u riil: rlo ra t , , , \ . , r(. ,.:l Iiri. mociificirri.er.idente ' rr,.r'r,l [[ir, vox1r1a, de rcspiralie;i cu refltrrrl -p"o&oJ 1". prraiiziite i rs(' r)irsi,r'irt. totare b nteraG 'i 'ir"ind,iiri"iLri sevcrc: lrlil'rii'i rkr 1bira1lie pir:i 1a afo'ie, rips:u rctteiirtiri iii." qr dispnec.rr i l r'r(i ()1 , inili a, les

tttrrr lr ll lr lit t r r . t r lir tr '- lr . I r iI r L'I oI r , r , I r |: L 1' l ttt Li rr, l) t t r , r r . t rr r r : r r , ir t r ;lr i lr . I r , . r ir l I o zr r r : r r lir r lr r r r lr r , iillr lt r l lilr r ir l ; i o: r r r l lt r oir l, lor r r r c: ur . r r , r 'vll l l l tl rr l rrl rl ti rrrr ;rrr|r . r 'ior , slt . iilllll. {"I I r t I I r I ) I , iir I I II i r,I I i rI i l r | |rI ( , ,r . zi ! iq. lt il. r \ r , r , : r r l: r f(rt. i l /r' pol i l r r . l'r ir lilui 0 , , 1|ig. ; i|t ' z0t r ( , ", ii iill|sl{, ziit lo|lr ir i sr r lr I r r r r r rl l tri i rrr. I)i ut r r cit l) 1) lt . l{. I i ( ll\ r l; t lt iit lii sir r r lr g|it r lt l, ii 1) l, it ro|ir r | ir . il: r ( i, rrl i i L, j rl i i rr z or t r , git t r lr ii ( t r isr ', iollr ir , r . , ( iij( : it 1, ) .Lir r r r r r ll, ilr ollr ili, r lr r llr . r . : r rrr' l n cttacl , t , t 'r 'elat ir . pct r r r ur I t ii, r ; L.r t slr cclbiI i pilf l) \ iil i( x. . 'ir r iir r r lr r r l i ' r' i zi .Iol rrti l r lor . iit r rilr r r . er . or r sli r . i lilr Lilt iJii,lxr lr llr . r r l r l, lt Lr l, ir r llr r jl, r , r r ili r r r r rU l , L U rcori apiL| elt iso t lc ( l( 1. t 1s{l dt ilt ioilr jil, ir i slt t it r [ 0 r 'i0lr 'r r lo, r . r lr I r , r ' trrrl l tk' tl ccrt Jt il ( I iisr : i', 1. 91i2) .I ) ur . r 'l'it at hn t 'it zi zilc r lr r r ilr liir r r ir i. r "r r r rrri rtl i l rri ngologic nr : Lt vir k'ir ljlr zi sonur e uir it clir . c. _\ lit t li, r lr r r , r 'r 'ill c r ,:l | r. :el ' l l oY lit lgic apai'in: . lur ingilr : ir c. . r t esit u clr r r r ict , ( r J0 r llr lr r r . lrlr ilr r r l. r.ln irr lLn;.rrl urror I'rlft/:tr (gt,ipr'i clir)- lti:r ''ttill|'i), dtp.i rnl i,7r{r;/ecloz,ii " l ro:l l ti i l poz.it it 'se lt it z. lt zr 'i, lr r ( t ilr ': it t er ul( ]dur ci. ji. r lr t I r,t ' r I i { rtr I i rrr,I r r . . i|' rl rrti i l r di " ql t nr i! in accst eil it r r lr I ] a l: nest czir i loclt L'lr li, , r . ir r lr r i ir r r ir ( li: r r r
l l l ['I'l '-]I.

f . 10,3. Paralizia nervutrui ilner{mo{Jatstri(i .l ' ru' el i zi l r ic] , t - ldui ] }lcur nogasi. r ic sr , r r r illif e"r l, ir t it i r ) l( ) r '||, I t 'i'l 1. 111] ) it r it {.r!zrlir-n si t'{,gola1tir1'.l)unli:irt ttttil.airrqlit, rlr.urcJa, iu^rrtiillt|rrlizil' v|1{' r li. pir lt r l, , \ ir r iior r , ir ) . \ , r r . , , r r I' rl rrti l ri L (hcrniviil t izut , liil; ot ot r . liir , 1li t l'r r , , {iir rl r' \ i l rl ni l zoi )at , i) : iiill t ullt ur ': ili 'ir r r XcghL1 it ir Llir . lhir l, Jor .r,, Lrlr dlr i: ur , r rlr r r ' 1r , . ,rrr. S t' cri trst at ii o ir em iar l: i0zir 'il r . ilullr i l) ill|1 uillt ir L ir |jir r , l iI I I r , I L|. r I , I ij'. , il r lr lr lr . r 1r;l rel i l or alicl'ior i si lt ost r "r 'ir li, t ) t 1, cluJlr i lt jiult ililii l :rIi trgcl uj . Il rlil, i. ul r r cLopllal iJl {'slo ( i; nlir lt iLl silr t air 0liL llr . I lr , t r 'r r lI r : r l. r r . i ,' : i i tttl !e bi .l t!t ; 'uI t 1t : 'cxLt t l: tt t ] ir Lt ;iili i. ilr t rl it r r L. . girl til ir Jit lririr lr r r. l rr llr r r ': r r L I l i )l ri i i !1r rl diiilolr i{) r t Lr : r lir t ir . . ll'r illlL; 'r lt ilc \ i'11 llli\ '( ' , lir r lr r r r r r l , ; l ' l ri i r' t' i tl i ri r, 1|( 't t '|l t r i {'0|; l- iiit ir }: L|: I I }|I I ii] . i|li, it i. ilr lo, , ii I t , r lr r r. r |r l , , - , '; t 1] ) ir l t l ot ji cr r lr ior iI o1t ir , 11ic, r ic r r olr :lni r r r r illr ' ( l, i r , il ir ll, . ll .i l ri l l .l l ri ).ri I'it s. ,,l rl . ;l.l{}./.r" l!oain hri iloska:n { hipelroikrclilll nt tir sitrourrolirlir rrlil irr i r| i i i r1cl r' el za i in Jr r ilf iLt l I i: r il lt r . ir r nt : , n. i. lr sli! t i sit r t , , p, t l, , . r ir r ': r |r , r 'l r , U i rrtl rl !i tra1;i tloglaJt ti] ilur r i- L t lo t r or t lI r , sir ir r r , lr sir t r r sr r lf i r . ir ] ( , i, ( liir ir r . l, r 'l rrl {l i r" i rl ual i z: L t lt i it r nLr ' ( ( ] ir 'f t r r . iil ; i . 11; policir r , llr i: l i ( 1) l, lr l i t r lt ) ', . . i; I\)pr,\,i (l i l : si Pr ur Ll, 11) E1) : .l ) Ti f)u L r auul ( r nr dic; iLt lt ,if il ur 'J so ( ll, r 'ir ill u izoilzil lilir r lr p; r r , ilir , r r r llr Tr rl t,l ruttrl 0r r t r t 1llr ] : r irsir , i ) lr r ir r ir t J, lr , r 'lit 'iiii t lot r I tI t r r i, iiI r I r{, , t r |r ' lr 0i ' r ) r ( |iit r . r r . rrrr' t11, , {[ ilt . t ] ii vr r ljlr ir ilir ( l- , lf r , , 1'f ) . li iI i r llr . r r r r r l ri tl i l rt r ioir r . r t ll1iut . cll ,t i nr,r' l r l rti u iir llr tt lir i , , r . t iolzii , 1i lit r ir t r l lr r t r n; r J sr l, r 'r lllr illiil, r '. . , \ l'. ot ) ili rrrtut, ri ctt(rt vrr Lor r t, r lt li( lr t uonl, oll: li r ilt t t lLt hniir islr 'r t llr .lt r , r r r lr r , r r ir iilii 1r 1r . r 'r l r,x,.,l .ol i ,l ro1rr , r c (1 i r I i I j I)i rI I ri I )i I r l : i, t . l ciir ot , it it l; , r ll{, i sc ir r r , lr ir lr . ir r I 'r llr . i :) ' f i ;l tt. it t t : , it , t |t , I t t r r ; r tr i', r , ir sir i ilr r r lliiililr , ir i; r r , ior silr r ir r r lr . r ', : r 1, . , . , j. ill, t lr r Jr ii, rrtIrrIr,.rttIl ttI, r lr hl i ( I j1I ir , r '{I ir ilLlr r , , 'r r ill ir r lr ilr r sir r or r r r . ol, ir lit r r r : r \rtr l l ttrrrtti li': llr 'it i t lt t lit r l it r l'I t t r , I r I : r I o t I r r lr li'ot r ir ii. ilr sir lir l l ,r'rrr r,rr i i r. r l , r,l l rr i ,ri l rrl l rr 1r llr r ) r r I r iI li r lr , r t r lllr r r lit r li. tl ) ' l ' i 1tu l,t , r t t lt , r l st , r . t ; r ll, . r ilr , r r zt r I t ir r r I ir r I r r r r r r r lr ': r t l: ilii r l. r lr r r r . r ' r ' i r.rr' 1:i . r i I r r , I r r r ' I r i | l, r ) lt t iilt lr r i I | | I il r | | i r ) 1llr ) lr {) 1, . ir lli r i r lir t r , , : r r r r r '( r , li,i, r t l ' 1 .rl 1 i rl rt tr.rllt L', , , i r lt ir t lot t vt t llii r ll lilr r 'pr ir , plir . . r \ r 'r . r ilr ' lllnr r . l( , l rur' :rr :rrni , i rrl l trr,trlr lr , r lr r r ir . r r r . r 'r , : r lr 'rrrr t r r r r r lr r r cr r ', , I r r I i: r r , .

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jriroi r,\ii(,r.n, i1,r.i'uncuri do r,,iii,ii,.,i"i sertltolii r.i "n"i,

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tlo urgolrt'it,.ltr etlzttt'ilo an dabltl lonl,-ptogrettt', tro(x1$il,il, ll'rrlro(rsl,outit .rlrrrc strirkrr', dispnoe qi tlisfonii pinir, ltl a'fottit'. Iltllllcxttl (lo l;uso osl 0 , iiur irrurit suu chiar abolit. D ) f'aralizia neraultti sphtal et'tern'so lllrt,llifcsLilprin ssnlno (lrll pil,ll,o. grrrtr*' mr6ohiului sternocleldomastoidian ryi tlrpez do llcocil,lsi ruanilirulf[ so I'ara,lizia unilaterald, a muschiului, sternoaleidomastoidtal, irr primul rind prin qtergerea retiefului musculat a'tit in repaus, cit.qi lrt "tirnpul miqcd,rilor de inclinare qi flectare a capului do parten lozitttrii. l)e asemenea, muqchiul prezintii o hipotonie marcatl qi atunci clnd lx:l i llllvul intoarce capul de partea sinitoas5, qi examinatorul se oputut ,l,cottt( rrriqcd,ri. Uaeori sd poatelvidenlia Di o ahofie de gtadc diforitc a' nrttqchirt ii., lLri"Ilin cauza actriunii sternocteidomastoiclianului de partea.oprrsir,l"ozitrn partea Paralizia unilntclrr,lii, sinS,toasf,' poate fie'ugor inclinat ci,tre si oapul lu,inuiciriului sternbcleidomastoiilian nu impieteazd, prea mltlt miqrrfililn ,,apului din ca.uza intelvenliei celorlalli mugchi ai gitului. In clzttl lt:rrtr' liziei bilaterale, capul se afii, in u$o&r[ extensie, iar bolnavul oxtrcttl,tl,t:t.t groutate flexia capului. Parali.aia muqchiului trupez re,alizeaziaurmS,torul tnblou cliltir: : rr,) h' rrrrrlrul rle partoa lezati estecoborit qi proiectat inainte I b) mugincir ir,tr ohlIiuaril a portiunii superioarea trapezului este qtearsd, ; c) spD0iulsuJrrlt vicrrlar. eite hdincit, iar r:laviculaapare mai bine reliofatd,$i paro proi{joltlliri in afarir,a marginii- spittrllo ir, tllai te; tl) coborirea scapulei; e) clevierea on,uplaiului; f) diticultatea efectud,riimiqcirii de abduclio 6i .tlo t'itlicl,r'r' a briilulni; g) imposibilitatea de ridicare ,,in coa,te" dirl. pozil,irlllllllnl,; h) rlificultatea efcctuirii miqci,rilor din articulalia nm:iruluil i) 1l,r't'gctlrt, r:,lieiului qi hipotonia muqchiuln) trapez; i) a,trofia,tnu;ohittltti l,rrtlcz llurulizia sittgulatd'a neraului spiual este raril. lJfl, :lllrtto rlo ttlrltrrri i. rrlrrerLnd, cu paralizia ultimilor nervi bulbui (in spccial ctt port'rltilo tt, tn i n nli al,t caresegd'sesc I X-a ii a X-a) (vezi in continuare), 'loluli, procese magnuln ;if sau' u, regiuttii, cetuicule $tt,lcriottrr ttlrof)iere a foram,enu,Ltri (lr)carcosteomielibice, qi nespocificft)pttt prtttlttco pahimeningita specific5, Adesorl, oparul'iilo tn de nerv spinal, ltilaterale nnilaterzlle sa'it lrrlalizii lnaltd (ca, tle pildi', sec{iunea spinalului in tortiut'1i*) itqiunea cerui,aald silrt rosponsabiletle proclucereaparaliziilor nervultli sltittttl ' Ane,tritmttl rcrlebraLe calo se dezvolii) il canalul slritltll superior pott,e t:otttlrrimtl (ljor'loohl;ttl' ^rterei spinal qi poate si plovoace o paraliz,ie 10(|6)' trrrilatoral.i' norvtrl

Ftg, 77a, "Astr'{te lch,rnatice ale examenulu.d lalrjngoscopic:

NDRVUI/UI HIPOOLOS IN PATOIOGIA 9.12. PROBLI]MD DF]DIAGNOSTIC n norvrrlrri hipolllos(XtI) lmXrllod: somiolofliolt 9.1L1. lnvostigutria limbii in sboretls rolf&ultrrln I ) ( )hsurva,t,irr 1,ozi1;ici ."i a nn;rootului gitutt. oroouto I) Inrplorarso mol,illtillli Umbll, solloitlndu.ssbolnavdul rl1, ,routo mtgodrllo podblle on t Imbn.

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:1.l:1.:!. llaralizia nervului hipoglos .l 1 1'o.rulizia u,nil alerald, tuiertru,lui iti.ytoglas; realizeazi\ o dtr:irtit. Irr' 1 r: r . i. ir- s iinit oas i i a ,v i rl u l u i Ii rn b i i ,,i n s i n u , ,. D aci bol n[r.rr] cf(.t.t{ r{ .i rz:r Ir',rlIrrzirr Iirniiii, wir.lul il(,csteiit est.j {let'iat spre par.trr boil}rtvii. [)l,ilr r( ttturrir lt[isd]iulrd de p:rr'lea opus:i ]eZiunii. I]c :rse:lt,,i,orr, -Eenioglos l:rl.rl .*'(l'ill] al li rbii fot]Illeazit o curbiL Lu corca\-itateit, spl,e ilrit,1,(.ir r :irrlloirfi. -\t:castii deriabie esto produsri ijrin actinneil mrifohinhti r{ii{). ,'l()ir *) ;(l ; r(,!(,:1tuea z:i in tiinlpul cfor.tLrrilor de t ducc iitnba cic 1[r,r.1rrrr irrl trrrril. Lint lx r es t c { ttro fi a l (i ti e tl a d t,* p a r' n l i z i rl l iLqi prezi nti i pl i l ' i .,Ji ,i bi l . ;r. rrrlrr':rlriri ljrnbii. 11 hernijinba rrlettal i: se poi remarc,a,.Jasci::r.lu!,,i.i tnt\t tt[/t)t: irr coridi{,ii1i:in cr.r'oieziirle:r sc:rllli lr, nivelul ntc]trdii ne}i.liiui lr1r,r,:los. l)fil irittitia {.rroliirI a ilctonelronik;t,. 1t ) N'rrroli::irl itil.atert;ld, a er,nri.ui ]ti,ito1lios praiar:e tuil.lirlrj iirrrrlr,rrri l, r'r'Ive al(.. t|r{rllliti,iii jirntrii. Acessta-nu pca.ig fi .r:ri;catr),r-ilnir"o i'ril, rrr ;rliii, rtici inirrrNr-rl 6i nir:i in aftrr.agnl,ii. Atr.ofia iidrbii este bilrt('. r:rl:r, rl. r,r,l.'.ti rr tll,{: o'i ca rnuitipJe li e\.ialette flscictlatii *tusrt irlr., \p tr si lrt tr:t'ii,ri, t!e mostica.rtie, deqlt,:ti!,;e lsi tle pranut$*re ro consou.jtt:lttr. rrt(,t afectat, gcnelal, !n tL, er:erlelrsi afcc.tiuni sa Sipeieijjlil(, . . llill(1il:r!11.1 I l',. \ sj -\ l, !l'r cr,r.rnt.o.tismele craniot:erebrc(l.e cit frac1,lrti rie itazli pot-1,:t,Dtlncr, t:tt' t\t t t!.1(\:)tit ()(! 3i't1.gukt]"ri $, nen:ui'ui hiitogios. Attetsriti,nttl qlte;:ai 1),,1{h;(lt, r,rtl' r'r':tlizlrrr 1:rr:rlizic nlilat,jr1r.li. a nerr-ulai hipoglos. lez;unile reqit.tn.ii t.t) t itltlt' ;ttq[te pot aft'cta re.rvi.rl ]ripoglios in poltiunea sa extracnrria Ilj,. lrr ;rr,.,r.1r, r,orrtliiir' rr: 1,t'itrrlc si sitnpatitul l.reriiclrrr l,id,lrn si llsist:im tra rrtr irrlrlrtr r,ljlii, soltprll dia pal,lizie ir11jl:tpri.li. p" 11.,tr-uh.Li ltiljOgios ;i rin_ rI|rrrr ('lr nl<, JlerI rartl-Tfutrtrl de a,ceeasi paute (Taverneri f.-Oel;.' :iirit.tr;r,Lrrlhial)otte lcsla s1i lrodtor: o henia_trofie a lin):ii, rrr.r,r, .r l i l .IrI r ' : r r r r r r lls or irl ri c u l .u l b u ri i ri l l e rt,ti s i bi i i tate i :r regi tnea' tl ' i g. D r,,rrL r lI i,.\tl(tt)1tt lrrtt:.yui.aL anti-ttiro.ficd (q.L4.) st si,nd,roamele tle tt-.[,.A. 1xtl, , rlr'lrrrlrr ,,rr ,i. ltzitr.'ro dc iipoglos, da,r de obicei se asociazil \si sentno {lo l.zirriLc rr cr,lollu,lti rcl:vi irulbari, preonnr [i simptome piramitlale. lr' irr,uil.rtLtnrtor*l,c fi it'ur.*t1{ttice ale g6,u,rii, cont'l,il.ieneanlerioare ttrl,.s,tv rrr':rzrr rrrl.rirrrir lrcrvului hipoglos (sinclroilul lui oollet). rreziuni trmorrlo r,i I.rrrrrrr:rIi.r'rrl. glj,ruii c'lrlili.ne qi ale gd,r;rii ruptc postc.xioarerea[iz{)lr,zi, :,t,rl|o)ttul. ..tr.tlil.o-qnu,rii ru,pl.i pottefiaurd, al lui S,icu,ril,aslpra ci,ruia, l.orrr rnrri l;i|zirr, rlind vom {lllorda, ;i sindrou,m.ele bulbare ct lntofestl,olt 'r,vr,rri rrr.r'v rrl r r i I t ilt ogk r s . lu l,rrttrliil.e lt .l?b,[e].ot otrrli{'(.lt superi,()are fto lot obsor,va, l)llrlilizii rl c n l 'r' v ll il) 0gl( |s . l 'rr r t l. i: iilr lint lr i i d t o t' i ti ttr' t,tn l ,t,u ,lp dl,i rr l rrzi rrrrii rl o fi tsci (xl l tl l l ti q..rri _ r'u l :r'l rI s r ir r s o{ r , s tr:tc rrl ,r' o l i iu l ,u fi l )r' i l l ti i i rrrrrscrrl l l ,nr. Irczi rrrri l sIi l l r,i ,r,1l l 1 :rl . I rrg rl irrrrI rrI rr i r r r r |ir | rrrrrrl .Irrl r,r' l rr* l rrr' 1 ' . tl i n r.t i ndttrttru[ ?* ut& tn,Lb(,r l i so rr ,tri l 'r . , 1lir . lir r ir , lr r , i rr | ,trIIrrr| ri Iil ' rrIrrr{ i o rtItIi ir rrrJr.l l t:trrl rr, i trl r,r,r.sl trrl [t| tsl i r':r(i :r, r llj, llli( it r 6i rrl l i l rrl :rl l rr rrrv i rrl ,r,l o r' .

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ri ttrl Irttto r1i tr: r lt t l r ii lr lx) lllr , r r l r Ir'rI i ' r trI ri t t I ' i ;i | | !i I i()I I I I I I I i 1, 1r ilir I r r r ( l I 'll, l, l 1).1| i ; l i i sl t, 1l) iiLl; llr por icit t r . t l': t , ; r r t t . , lt ) ijl) [ i s{' r r r r r llt r llt izt 'r t zii1t t 'it t si i tit ot ilt I tr,I rt i I i t rrI rri , pr nt ) izic il) $ilr li; ( f r it liiil, ( r r lt '7ii vit . illr t ( ( 'll l rtt' rl l i ,,,i rt, i l rl ri ,rrri t, vi i l ul u i palz[ t ului qi r r I r r I ir r gcllt i) li ( , \ - cr ] t . uill l) i'ir l l] r r lr r ljzi( 'r r s( , ( r i: r lr l I rtttt;chi l or st er nocloit lolir ir s r it lian si t r ; lpt : 2. Ut t oor i I u1 li r r lil, llt , {i r t itcrvii simpatici celvicali, o1t sindrom Cltrtdc liol'nrlr(l lkrl'tti't (liory I I,t rol al t., 1.969). tr' actot i i et icloyli. cr sint i : : '. ) I r aum alici, in speci: t 'l, Ll r Lir r , lr t l qil, t t lr t r ; h) Fat:tori, ttt.tno"rali pi c,tinpresi,ti (turnori ale glaridttor ptLlrrlitlr', 1f i'ilrrtlozr', lrctastaze l,:.,cele,adencpatii, llmfosarcorrno s.a.) ; c) l:'utlori iilllrtutrrl0tr (par{}ii(lite) :iircese, celirlite q.a.). 3) ,\i xtl rr; m r l, de hem ibazt i ( sit t dNt nLul [ t t i G alr : in, sit ulnt nt ul lr r i( it r t ] 'Lain ;i {ioci.n sau sindromul lui Bertololti'G arain ). semiolagic este constitutt tlin po'ral,illi l:rt11i;rlr: tlt' trlt i I '1'ablott'l' {'ra}iicni, in {olmele lipicc qi completc fiintl aiccl,:rte tttrtttr c|li' Il1 l'r'r'' r'lrt tLc nenri cr:lnleni <le o p:trte, da.t cu clemsili-c s(xnioloiliot) ll.o tLrirrtl, I rr|i:r 1;i l e, i n funcl i c cle sediLr tinil; ial el leziunii. il f olt nt 'lo int 'ot r t lt lt 'lr rr lt 'r t t r r rlrotn t1o iii:nihazri. tttlii ncrvi cr:iiricni 'q1ni,cruli:i1,i (f1'{'ill rrrrlil.rtit'rt l. r inti ftecyentil), i:lr nltlrior afect*rorl l]ervilol ci'lnicl]i sc {rtrro lil'tlitt rrlr' rintcro-postfl';or, fie riin srns }ostoio-alltotjoi', oll plirxlet'i'rl iirilirll,i lir' ' rrcrviit)l; c1':1ni{,ni ijlllrl(l lrltl, lrl rlin fosa oerebralai mijlocic, fie I ultilttlol (1r r:ri ' Ti crarL ioni ( I Jlom or r t i si cr ) 1: t b. , i'olr r J, . ,llll; 1r r ' ide. I logcr f ii 195i, cit a1 lillri:illilllli n(llvi rtitlli{flIi {i,' i)irllr ir, iri lite situt,irii, ito llot :lio!:ita li unul sa'.1 ;,ontloittterali, (Arsol]i 1i col:r.b." 19?3; Iloiler iri c(trlJ-), 11){i1i) Gr;lcirt tL'-t srr sl)rrr,rl('rr' liultir ;remc, itr tvolttfiil sildrotttt'lol romni: dc ltitcltonsiun{r intracrtlltiat}li , cero iw|1rc ndosea1,xl'(!iv'{ r, \IItrl,r]' tllncit) 1r'rtl rltr lt.rrtr r'{lcruihri pi1:iht', r::u'o aIliie m:i t.lci;rtrnc. ll s i11{1ro i"lr::rirm sc ilcrrla'azii, llelltle tls ltziiute lt, triittlrilot' senzitri|rr sr'rrzrrIiirl{ r rr rotorii iltr':riier-r"ilxialr. de h(ntib,L.ii. i'u:lo: ti et,olttgtt-:itti s iiztl toa ,tictor Cor{:i.11 ::.) ' 1' t.mor ile: t t r t nor i oll] 'N sil {lt }z\ - o1t alir r ir r sii; i lr , lzr i , 't r it t it r lt t l I r i inai , j{r ss; lLlr ll{'^t lr , r t lr iI r 'i lir r , ' Lri )Irorici i l l l rI ] ct di] gr lccl|i't lin: iil'llct vol b:l de tum oli linola, r it r giclr : clt o it l lt lo: t zf i, bll: r ll t r lr lt r it t lt ii. ( lr 'lc t r r : r L l l tccventc $i i rb t r r lt lof il0 a, t t r ic: ulllt ', lli'lzit lc.r illLlr : r l( rsi r t lt ' lr t t it r lr 'lr r i ( ir t r l' " t r r ',r t t ir o: rt r r '' .r,bi cpi l cl i o:rmc alc : j1) af jiloi' bazalo poslt 'r ior t lc it i r llc r iilLt ut t ilt i i ml l sartl rl l trl o : llo l inolar ingt llli, llit r '( i ir t vllil( r lLzi'ot r lit it t l lt t ilr r liv. t r l' rr :ofrrfl l l ne), 1r s cut it 1i t um or ile 1; tit nililt : lllir t t lsclot lllL, zci ; i lt lr ' l I I I I iI iI : , t 'I lt t t t r t l' Llilt t oliit r }I r lir ilr csint qi lco: t t t xr sllcoim c osl, cosl ) ' { l i l rrosarcoatlc, ' lni Iitr.\taclri(), ir,lr:}nlalului s:t,l alo glandclol sllivltlt, ({lrtr;1'rriilttrr ;i rrolrrl, , I ' r r kr lr r r zr ' 1l )l i 5; ,\r' sttr i ; i r lollt 'b. l9?4) , llli"r t Lr r l ; i t t t r r t ot ilt t r r it r I lt slilt 'it t t tI rt t t I rtit t r' . t no llliil) ) llli' sllt l 1 rl l l tri l ri , r,i t lt it ui. l r lir lllr : r , alc r lit r ciu ( r it t t xt r lin lll0llllolllllt t t t t t t lt t t ', : r lr r lr lt o l, Lt t t xlr i i i i tr ti tl l l rrotr,t coil'illo, I , i'( '( r t t lt tli . jir - r gcr '1it , olr r lt . , lllt ; lt ; l1) 74; ( , \ l; cni cohlb. , rl )i r,Ii l l ,ul tti r t igest iv r , i 1i l 5tr ir id ;{i r,)i n1i [.rrrtt lnir 'r ', ll] 51 ; {llalll ; ii r olr lb. ' 10{iL) . \1l ;s l rtn t gt i lllt c llt t l, t lt t l, ct 't r t it t t tsir t t lt t lillt t t l t 1o lt t r r t t ilt llzlt : lllt t t t 't 'l l,i II I I j i slir t lt I ot 'lr ipil'lr lr ', t ' t I t r I t III 't t ttI ill{r .j ()r I{1 ,1' 1,i rl ittl ' r ri rl t' , t r t t 't Lit t git t lt t t t r , , r rrrrrIIoIl l rrr.l r r zr r lr , , i, t t t r t ot i t llot t t it r t , , lr llt slt t r xr ilo: t t t t lr ,t t t ii'I oI I r r r I 't t t t lllilr lr ', lt or lt ll. ir r {. ir . ( liog( 'l 1i cr r lr t lr ', llllill; \ r r il'! r l I ' Il Ir,r' rrri trr' i ,rit 'ir lr , r : r l: t lr r i , ol ,rl r., l l l i j i ll) i 1) .
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, 11)u'lt rylrrlittrri t 'rr: :t t t . | , rt r : lt r nt t r lt , t nu l lr . lr i rx r l i ( I I I I I i r| | | I i ( ( I t r i I I ; r r r r u . , l l l ,' 1, , r' llll rlI Ii,og r't ;i r . olr r lr . , llt i; ir l; . r r . t t ir t ur ' i t t f . t " r t r , tt : r 'r t n t \ t t ( , 1 ( 4 i l t t 't , i , ' . t tlitlt illt t n t (l(is''r'. 1lJ 5: l; . \ t . f ir ' li , r lr r ilb. r 11. ) 7 , 1 ) , rlt (lixlitt tro :rlt tinliLjplr , ( , r L lo( . lliz lt ( , baz ali l , \ r s c l r i s j f ( t l l i ) . , l 1 , i , l ; lj,,,r | {,rl l).. t||ri9 . / . ct r rirr,
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ll'. isl,rr roitlrnorLte fornto partic[ia.r'e dr: polila'Jicu]orcn.ite t.ririiiglo r l, trl r (lr r ilLr ir r - i3r ule , c n a l :e c ti l ,Ie ab i l a te rn l i i ( ul eor,i predami nal l t rtl i l. l,r':rl :r1 r r r r llir |r 0] ot I J ? l 1 ,tu r' ,r i j oi ,, }e - to o l i i (i e rre i l i e t' ani el i si a ocL1l 0tl l ol , rr ,Ii rl rr.i: r I ir rr r llr ur lir ll -c i to J o g i c :i . ru g e n n e I,l l IG cl e ]{ ' zi ul rc trcr.,,,_.,l n 1r''rrt.l l i [:, s i I r r r r r - ol ul i e fa r-o | r.b i l :],(Iri s l e r. l 9 i 6 ; K e1,z si l :{ ol derror"111i 6; \ l rrr.,rl ,1i I lr r lr il' s , 1l|fi 5 ;l l a v t, 1 9 6 ? ; l l o p o ri c i u ti P xsr.i r"i !1,!1). Fi ri l tru , r, ,,i /:l rt fr ir lr f ( ) pllr it i: ilu tn rl rl i r ,,s i n a l l ' { } tn ullu i Iri shtr:,r,{Ii etz ;i f{{ ,1!l !ti er' , l! ,{;). l/ / I rlolr. titulrtrt t( ll( u,nqhi p ctri<,,terth elot Il{}t ilrtt.rni jn uttt!t'.':tttl , rti r,l t,rli,s i lc z ir r ni ?r l ep c re fl ri l o l II. X , i i (rareol i ,ri al e hi pogl o; I i l i i i ), -\I rr rlr,'r r.lri |rir lt,niori (nlcnir']1^io:)rner tur] oli c}itlermrli(lc. glio:rrti ._ereI , i,r r . lrlrrrrrrrgioiln)(r arl,{rbol(}tse: tllrrri]r"i:r,lcpilrlii Lltelale ii !entrir,;lnlui r l 1 r:rt:rlc ir , ir r r r ur r i r ir .r iile !:i o n l u s j u g L i l tr, tu rn o t,i mettrttrtl ce, tl ent.i noi r.i t;e i, r:Iu i ,:i s p i n a l u l u i 1 .,\.1 ,& ]..i | * i (j i di .i ? '|,, rrrI:rl ir r I r ' ir r r r r r I r rr ' ag r/i i sl i cr: 1i .,:l ct )t:tn t i tlt lnint ) t i; ( de (i ' i (rC .t:( ,e b rud p ' i .l ta ti l ,rrti (A l aj ol ani l e qi r:' ;i rtl i ,. r'rl :r : l i ,r , t lr ; ir : olulr . , 1 !i 6 9 :1 rs e l l i ;i r' i i h l l .,1 9 i .i ;Po l rot' i ci Li si P ascr,l $31). l"l;1.)t[{'cttunl inlranelraxialtr cu loziu}i lr}ultiF}c dc nerri eratrirni.

| ) ,'iitrtI*ttrttrIt rIts{ti|||!t'atLt:ttu,ttclti ccrebrctl, \1 ,\i t t , t l , r r nt rlr lu tl b (i .t' / ) ' \ it t , I nt t t r t l ] nt tl n !u i i .q 1 L (l i l rri ] o i t, ,U ,i l l entoul .ti S cho{.i), l tu+ '. , tt tI t , , ,rt rt I tnit ).tl;t'tt ul ltti Dljirit.t, :ti,ttl,ro'ttt.t[ itrltfuLitrr a[ !ui, ]Le|/toklI', ttllrrl lt,:lr'tittt xrrtr.h utt i;tlr:t1itr, oltr:t,nir ittferioard) .qlrtt tiduae selri,,logic lilteta][ jn1'eriotr.t! (r'esi.x,t.lintl t,r rlr , l r rrrjrrrrlzii itrrr I ielliJr lclil.ieaoI)1r'ri i. rr, || r i, t ir Lil( ' lr , ill) i (i i o l l tl l i i l l i ta tr!i rl c i L u l l l a re, i .ri scl fi ti ilr ]neor.i :i i ' l c o ()(,j II 1i { . ri e ti p ta h rffu (p l i n l ezi i rl ea r 'rr i rrl lr " . iL. , . 1 rI i . r }rel gi i ci i i ri l i ei l ) r ;rr fr l r r I r r liz ir r ir r r ilr rtc l l tl i a , l i tn b i ;,o u :rl i .)fi o si cu fasr:i t,ub.ti r, ai ,,,,ti ,ri ti l'. ,rrrr i i ,,' ; r lr r r r r iLr I r Li i r t l ri p i i g k )rl rl u i (p ;i ri i c z i n n ca fi l l ,el or r.arl i cui i l .' ,,al o : r, , tl r, ir r t , r r i|r . lr r l 1 r;r'i l i r,:r-h rr]J ta | i tl i r:g i l tn e a i -i rLl bar i para rri trI i :rl i i ). I rL l rrl r rl r lit liy , t : t t , it ui r ri l L l tl tr s i i x l to ttr, ]-.tj ti l tz j l t nerl attrl l ' l rt zonc j rrl r' t,olr r rr,', r'r illlr r lr lc c io 1 i 1 _ l rrrrl i z i e l ri b ,ttrl a l :i i i pel cl hi i IItr i pri n l r.l l tzi rr rrrri rr'l o I r r I l, r ' l| s lr it [ t I ( :l] l i i (r' i o :i l ' c ). '' I t : ; r t lt t ) t t t ul li ti l ri ' l l .i :: (s i l i (h .o i tl l tI n u ol 0ti l Ll i l i nr]-,i g1111) i .,!rsl i r lr ,l r 'r l r ' ; - , ir r r r iz r r ollr i::i l t r rrc l c trl tri l rn l ri g rrri (I]i, X ). tr,l l duri r sel r;n]r,:tj r, g o -r.r,Io p a rti . so l :i t i r r;1 . i )r tl l l l l () lr rrtrl rl rr lt r . r r r ipr r lr r liz i l l ' rrri rrg ol a ,ri rr , r o',l ri tri rt r , r lr r z ir r t t r l , ri r rtu i rl l J i s i :i fi t!c i a .u l i i l l ti n[)i r]otrrl l rni (,fl i l l l rl rr I r'i rtrtIl l' lf lr z lr l, r r lr i | rtl i l trttc z l js i /rl l .rr () h rri i i i ] ri l rrrt,sl r,zj1t.r' o rrr() l :i l ,' i l i Ir' i t rrtL Il rr|rr I r ' r ' r r lr i, t r , ir lizi rrrl s i rtrl n tz trl l tr.i l )tti ,l ll ' ol .l tl ri tt (l ,otl r si l ,i r' trr., ll)ti )). i rr lr r z r t lilt jr r ( ,l ,rtf :r i rs o i .i ;rrl l ri f,' trl L rr l r.trrl rr.l ol t-r, tl l i n l r' l i t,l l { ,,r , , , r l ,ttl tti r lr lilir r t r r ) , t ' rttl i rtl z .;t ri r,,i r,,rttrtl i ri ) l i l i rrtt ' i .l l t trui l i ,,t:l t | 1 l ' \r'r' , I ' lt ilr ) I :1 4

: 11) int t l) r r t rr lr t ir t t lr lc lczt l', ) E i ttl tottr t l lt i St lt nt r ll 1 t ut lt ot t ui t \ t lt ) slt it t lt l r r l : l lill( lr 'lt llli slr illill ll( ( 't 'sol, slt t l lt lilr t 'r r lt r t tttri i tti tcl rrttl tti 1 '; lgr v ill lllll ( ) l rl l i l rtl rrl c l t,k,ttt t r iot t lt ii v: r , 1or r lr it t ; t L Er r lr t ir t lt git 'st l t r lt t lt llt r t 'izt 'lt z; I V Olill', lir i, illir , lr r , i, r 'zilt , r '\ 'ocale, st {, r llo( il( 'j( l. ln, sloj( liir lr lt llli Itt:rrri prtr.l rl i zi c ' ri, tlaoezului. '.i -]iip{ )sl( i(') irrlr'rl ('{inthomul s})in{} vag'o4 )-ELnrltontrI lui Jotl;:'rttt' 's ( t it t t r t t r r r l rett{ l ; paral i zie unilat er alii a r er \ r ilor ct anioni I X, - \ , \ I irirr t()lllrillirl(ll helniparez'i le cal'c se poatc asocia o .lirlrLi ) ,si \II, ( ( ( I t t I I I I I ll) {i}; ' ] I e"Ye] , ' Loeb de c t ai' 'I ' I , $i tLi ni l [ei rr' ' i A l rj our nir r c, ] 935, 196i ). lui -{r-el1is, Srhurirll iii 'lrr('lis('rr -{rn aruintit an1,eriol'cir sin(lroan}tlB l r,i rrt,cel tl l ai ad eset j de or igine l}eliiet icr l "i I l|] coli r i. c 'r t 'iililr t r '( 'ir lr r r li] . cl l.ezultinil dinir.o-leziune l]| ]}el]-il(' r.enpo.ti\ i h lr;r t.lul g]i||I]'ii |'l||)l(l (} DoBteri{}lte san al sr:rliuhli rctluntili&ll llr r'l1L'le (irl'rlli ilr r'lil'(r s'illl I)l iir:r.,srt rtu.l,tttt ir: l6i,ni dir rezultii elc iluso printr_o ati'gire br lb:_''ii, (litr l|zirrlri l }Jedsebi iu,noruitl, intrlr, SaI etitrabull-litr e, ii nttrtrtti rrll('oli trlll Irrlrrrrr) srlli'lililtl fie i,usct are,8:lre realizeaz:Llie sLrferintc pnr nulleartl, (r\l)lit'rr' oc zt,)l}c, tiirr r''ertl' folrrr.L{iril,i pirr nllcl6,rl',1,ci li aie altor 'frel ',rsocie'e:r, tie alie sinptone. rlupil tc'iot'(l'ii;rrrt1;lrr': ltnriltlit-:rr ll.rr si ''xlir rgOi, !os"" ;i cohb., 1969: trir-rpor-:iritsi colttr" 1llE0; I'oltrrlilirr 'i paseri , l gsi ). fn acest e'nlf im e ( r it z1l1i n[ se m ui lor t c lolir i t jt 'sit r {lr r ) ir r r r l lisoir' ci rie fallt (le lrl irutl'(l rrl(' Jtif sau Scbmidt ,\volli.q, t)rue. ,,cla!icoil 'iio,ttu".n,, 1"llsclilalc bulbrre asindlom rctr., olir-lti \1-itllcttlrttr'. ,'. tio,,l si |trsdl, 19El; Jlrltttt i.itt 't (I'opovicirL r;espectiv sin(lr{lrr interoli'll ) .ol ab., 1f180 ). :i i 8 iti.titontr1 lrttti'cl' ctl tttttbultri. o'intlrorttrl listrt'ii [tullnrr Iultttrl" xrrrr*rtr (uL l.u,iD, jt,i't' I' sit'ltuttttrl ltr'[ 11-'1[lt'ttbt:r'11 sittt",rc,niu,l,':'et]'o-()1.i1:qr tetizr::rzi s.riri.l':ri' c:rttr ii' (:?rebelodse ,ii'ornt,til arlcrd Ttotl,irinlr:rioar'' : rurlltoaleLe llil (sau lttlntiltilrol '"" - .!.)r',tc,,r,,,Fi Parl', t:J lezitnea : e) IJemianestczie Jocalizrtlii rrrrl|rr (terrno-algezic[ disoc,iatr: ;i ) rnaj ldesea 1;ezit) fa'tiali^ cel t lc r lr r glt r li{ir ' r l' f our lio 'I ullr r r r ir i l i i i " .l tot" ,,l cf t alm ict ihi; bt .r-oclllc . 1i li('r'rrrtr'.l " " fri i Ultruil'r Siitdrotrrrtl t1 ; {i,tr.,t .',i.*,tgtti1)6i ptrraiizia cotzii ( li r r ir r r r r ve. lilr t r lr r r '. r l) Sit t , L'. r r L sit nl, r lir c coloanei l i i rrt.r" , l ,ai ri t" r iuir ell . '- , i. . r r t Lr ii. . r 11rsr ' t r t t t r r tt' t r tli L,,ri .i i ,i o-l ,:iitl i l n nasc, gr et , , , r . iqii . t r ir t r : r nr t t t ', ; i t t l it t li't ior " t lt llt i : I r Lt r I 1 I I I I llt r I I I I I i t i t rs. l I,I{ l tul nl ' e: e) l i i mi siniir ijr n 6161s11sLr (rl rrr:I r lisr "'i: r 1r '' t lr lr r ! r I t il) o^'t czi" oPi, sd: -' f,)t Ttu, r lea 't llr . zj( 'i' { ''' r r ilir 'it ' t r r r r l" i', r I r 't 'r I : L1I rrrl t' rca respi t,l ,ir r t l f nll ( nu t ot t lcr Lt t lr r l. 'i li111r r 1 l) 2 r : ', balr . lliU; r . ,l ,.ti j rtat't r ( lr il , it , t lr oDt t t lt r i lt i ' ' :r.i ii,.l j ,ste l " ri r,o t r nt sii iecnlt o : l, cir r i, r r l, r r , / / t l, , . lr uit , t i, (-,.oziPopoviciu Fi ]'r.'irltl' I llSll : ll: ol[cttbt"t'!l ' l " orntu r lllt ttl tr ; t ir : r i, 1i1r icr i' 1'lllli il t {) st r lcr r 'r isit t lc f \ ir ll1'r r lr l't l ir r l$ll " I r,l l l ri rti i ,l rti ti s1 1s. ( r l) I ( t r r lil i i i tul rotttttlt 1l'uL[ t , nlt t 'r 1't li] 1i"' it ""'l'l't ' 't t t r . lr r t xlt : i. t lllil( li i, 1r it r . I it I I t I t t it 'r r l, l. r f i ir ,rr ,,l ,rj r,l t,zi l rrr , 'r I r li( , lc1l1li lr r r r liiJl't r . i |ir t ! I t t l( lllt t t Lt I r Li, lr t 11r 'I '' \ 1i1r '\ r c}] isl11r 1 1,,,,t1,,ti lt' , {rl l l i z ill( illll sir nlt om 'i'' l ,,,i ,i t ,.i a,i t,,,t, , " i. lit , i'r ', nr r . lLii 11. lilr r r lr r r i sj r , ir r lit t . s f , it 11 I r r r ( i l) r r ( r r r l r,:,l rl i ,rrri tl i zi l l r lllr r lt st r llLr r t lt r r t sill( llt ) r r lll( 'lr lt l'lilr lt r 'it t I '( ) t t t 1t I I 'I . t I I {I ') f r i||( i|( ||t |||I l ri tl r,sl ,l rrr tl l tct t r r is, t 'r t l1r lr t lt slr ' t lit lt 'o llir t t t ilt lt t r slczit " t t t t t ilr t ll( ) r t l
( l i | r t l {\ i i t 'l l l i l l ( l r r r s r . l t i r r r l r t r r , I I i t|l rl:rrllllrr' . t i r r i,r l l o t ttr r t, ttr i ' i :i ( r l l l t) ( r l ( f l |zi tttto l t ttttt'l l ,ttl tti l tttl l r i l l tttt' r r l r t ;r r , tr tt l i r r r l to ttt r t'r i i l r tL l r tt l i ) l l l l r r i || I ( 'III||i II l ,l r r tr ;i l tr r l r t t t t l l l ttt l l ;r l r tttr I'i N r r "r 'r 'l l '' ( 'fl i r " l l l ;r ( 'r 'r 'l l i i r r r l r r ,l t

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( , it l l ,i i ,v i t,rl rt,l rl .r l iitst' l ,r' iIl ttt' ttl l l r l r, l l ttl rl t' l l z i l l tr(' i l , l l ,l ' l ,(tt' (' { i l 1 r'r, tr I ( |r I ( r I I r ii, u l Jcl nl l (fl ol ' (l o.$fl l ori tl l i i l l rl Li i ttti ,Irrrl -i i ' Iii , irrrl rri , rir r , r '. t t 1l' t r t k rttti trrr' tr1ri rr Ii rl rri rri r (l c o b i cui i udoml l l ] vl l go-i i pi nl l l tl l lrr,i r.* i l ii, r r , lr r r ilr r ilr r i (tri g r,rrrri rtrrl r.:rl o Io l lI l, o l) u1; in& 1 ,i n s ; c o r' D ttlt,l i rl o trrL s i n l Lcl ei i vesti bul l ,ri si nt l :o{l ,r1]{\ rrrir.r'r,srr,l,i, r[c irndc rezdltii rin ;rt:t,tr';.ittdt om vestihulo-cclebelos, ctl m&r(! l czi utri i l h c m i a trn i o !i l &l c ro pul ni c de l artca r r r r r r i- i, s inorg ce ,c r,.r I.i i . " B oid h tPl , t' l 9 6 i ) ; (e ; l i n droamol e bul bare nucl c:t' t r L i rz!)rI lr ( , i, ll) 07 ; lezrlltir' mod exceptional in iz,,llrk' (Avcllis, Schinidt si Jackson), care

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1960); rl., scncibililal" (SaradiiSvili' i SIr,!- ,\t-cvclidze. r'l:r,rr I.rrlbrrr':rri lrr lr,.rrri:r,rr,,.lr.zi(.alLerni pc fali Ii pc hornicolpul opus; l'rmo rlgnzi('ir, r.rr lrlrrriri,ttt'slczic termo-:]lgezlca! contrulaieral:i, ; cu tulburriri dc sensibilgczicS, hilatel'ale pc faJi, iar pe cxti'cmititi doar tle pa'rtctt' lrirr,lr { r'r'tmr-it \Tallenberg ii,ri, tull:urili^ dil pa'rtea cor',,trrrrii'lozitrniii 1g1Sinoro:r,me (I1liJu, cle Popoviiiu qi Pascu, 19$0); (h) Cazut'i 196i, ciir-r,t ,.rkrl r,,rr,rt,lc bilarerah llc foir'i,pre"uul 'i ''aztiri cu tulbll, rr Irrll,itlllriilt' s, nsibilitrr,t, dar lucitlizate tloar perioral, inciusiv pe 1imb5, ctt r':ui sr,trzil,il'c bilate-ra1c, i9G;,. lr,lt cul{r,b.' :r.:rrlz ir. tSr ii ' cu interesa're mai' entiinser. fi de sindrom lTattenbtt'g t,,,riit srnttolc,ltice qi suferintrl gi ast ciazS,. (l${'l}) care. 1965), 19i?; Scholjt cohb., t),rrlirri, i,rr,l,.ilor''r'r'llnicni VI li VII $i chiar alectarea fasciculuiui piramidal (clt 1r'rrilrr,rozi'1, controlal,cr:t'lii), sau forme in care coexisti' qi trulburdri vasotneori cu algii &sociater,r,rl,oi ii (ctr orractci' :tltein) fi llgii hcmif:lciale'sub-bulbal sinlrcm'tt'l (lsch, S-t relat-at 19;7). lr,,rrrir,rrr';rrl'it1c corti,ralatrale qi ClaudeBernard -llpocstezie faciaii, siadrom cerebolos ,l t t i ();alrlii (crL -palte, hemi:lnestezio clisociati qi eveltuaL hemipa-rezri ll.r'rr.rl rl. rr,r,r:r:a'i dar ldri atingerea ncrrilor , I-XI)' r r rr r i r ir I iii rtlrtrrilaieralS,, lchol'lt 1 lrr .i r',rlrr,lr. (l1ili5) qi l?0poriiciu 1i colab. (1980) au -rclatat,. qi sindroamr! {le paralizia perechilt-rt' irrslilil;c si de sintL'om Pa,rinatd' 52111 \\ rr'llr.rrlx,rlu supe'rioar(') )iittts{r.i, Icl'in l"zi:Lne;iaarl.rci |crcl'ol.Jtl'{c Ill r .rr,'il\ crt hAm!anopsir', rizualc de rip uc'"ipita). asocjr'1e s,',i ,i,..,,,i.,.-i irlllrrrtrrri alcxic (Ilcyer si col*b., 1956; tr'irchor-$icolab'' 1961)' r .r'ilrlr coli irLlii satL hemibulbttlu'i li ) flitrl.roirtu,LLui lJabinstii_Jageoltc sau' sindnmll t el i zeazit-\-ageattc sr 'rut,t,,,t. \iu,lr,t,,ul clqsi" ,l I'L; B';hinRt:i 'arac plin ll('llri nohtralatctali' bcmiplegic ,.lli,'f,',,i' ruir, tt"rniftnr.'r:is",ll ronlralale[a1'rrr...l,.zrr' p,' benricoti:ul \sipe.llelrulafa ]l)nl' Icl r,r,r-iulg"zicli somlrir (ipsilaterx]c), lllteropu-lsie Lhr,rrl,r, IrIi|I tlisrncltir',Il,sjnergie. -prl'n ocglurllrt' de l'elopalaLuft. (,r'j plin Lerrriparllizie t'lt'il:u'' ti ulr( .tulbur';rr iphll*1''Iali,o corzlr vocalc' .r rl. r,tt Iritc ii Jlriu l':lliLlizil-l, - Chenatls este asemd'n5'tor cu sindrorlltll 7 | sittrlrotntr'l lui C estan t,', ti,,r,it,*i.i N,ignnrt,', irr labloul clinic asociind totdPauna (pe ,lin'{itr r,cestui sindrom) qi semne datorite tnei - leziuni * nuc.toullll ,'i,,rrr,.rrilkr a I'[]ului palatului \i 8' corzii r rt|l)i*I , l0rlpoctrY cu o par:]i;ie. ipsilatera15, ltt'i Dei'tart se caractelizeazil' prin crizo vcrlri' otnt+I,lLutJleLtIL[i ,\ ) Uirul,t nislt'[inrus orizottl*[ r,ii"r"'iri,i *ii si",,'i"1.. 1,t,'',ir,i"nitlc 1arl,c:rlcziunii), braiTelor sPro plin devielea i,iii',ii'i',5i ",'iti?,tlt $i/iau rotatjor)' liur:um 5i
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},iind pe prirn o"itnlirau ; (r) sin{l,roame

l e Potttitrc l\) il in tht ru nt,tt lizt,ilzri,, solrriologic, o lxurtlizltt r.r'rr I ) fiitxlrtn ,ttl ht,; "ill.it.t(t)d,-(il.bld. (10 l )n' l ' czi l l' l {l l l pl !l ' l !l l zl l r rrl i rr,Ir i, ' I r ir t if lt ilii,ilrs i L u l r' r' rl l i ,i n s o { ' i l ,i i ' ,rk r o l l i cci , l !(l

llllr 11l rolrv('1'g('lrlr, tttuilrlrirrltri dlt,pl rrxl'rrltt, illl rlilrlopir';li sl,tltbisttt l)t'c( ltllttcrill?l. rlo o Itorttipltrcziis:lu Ltotttillt,gir, r.ottl,t l!) lli,nilrotnul, I'or:iLIc irt,lrtior sau sindromul Itr,i llot:i.llrt-llillurrl-' (irLbl,a: prirr prlldizia rniqcSrilor ooniugatc itltr ttt'ltilot' se ca,racterizeazS, illr'o palirealeziunii (,,paralizieconjugatii direct5,"),plin paralizitt,lrcrvikir' (.I'lLnicrri alo l,lrllfii' zo ele dosi:tlo YI qi YII, iar cind leziunea depLqeqte rrpilrc qi o hemiparezh contralaterali. Se poate asocia ,si o hemialr('Nl('zi(r il lr'tlirorlternii facio-colporald (facial5 ipsilaterali, fi corlorall, disocial rulgozicl, de partea opusi,). 3 ) Bi,ndlomul lui. Grenet satt ,,paralizia sen.zit'it:ri"tnutt,ci;ltir consfii rLirtl,l-o a,restezio faci:lll ipsilaterald, (de obicei termo-al61ezicii,tlirl tttrt'oti :i globali,), ;i ilintr-o anesteziepe h.ernicorpulcontrolateral.,{t[r'st'rt,sl a rnuschi]or mastioatori ;i ttn hcntisitithottt rusociazl o paralizie ipsilateral5, r'orebelos ipsilateral. - Cestan (sau' tiptttl str'perior al sitdro' 4) Bi,ndromul lui Raymand, ttului lui tr'or:illb semiologic, o paralizio a miqci,rilol corlitl$Ltt" ) t'ealizeazia, rr,loochilor spre partca, leziunii, alterarea sensibilitiii,lii supelficittlc r1ilrtrri unale, semne cerebcloase (ataxie, asinergie, dismetrie) $i milcr:,lj (lo 1ilr .,rtrbric" (atetozice sau balistice) la rnembrelc contralatoralc. i ) Bi,ntlromul lui Gelli esl,e asem:inXtor cu sindromul lui i\l illr,rrl ( lubier [i cu sindron]ul hLi Raymond -Cestarl, dar reaTizeaziu1ri' 1t'itrt lrlan o leziune importa,nti' a perechii \rlII, cu snrditate ;i cll r','rt isii, plcc1111 Ui cn lateropulsii de acceaqiparte cu leziune?)Ia cnrc se iuso('iir,z:i l)l,r'ftlizia motor-ocrllarrr1ni extern qi paralizie faciali. In cazuli]c cu lt'zitttt,r irnportanti, a nucleilor cochleo-rrestibulari' se impune diagnosl,iclll. (lili" lcnlial ct rln proces tle unghi ponto-cerebelos. cerebchxr:tir" 6 ) Si,nd,ronul lui Pierre Mari,e-I'oi'n saw ,,hetni'pa'reza u lni,' Marie ,s'i Toir (,,sindromul latera|') inminunchcazS,, $cmi('|)git'' lulburii,ri de echiliblu ipsilaterale, cu clismetrie, tlisilergie $i dindill(l(x'o llrinezle, rsi, exceplional, semno piranridale conl,talateralc. ntioclonic al trunclzittlwi cerebral &l lui Gu'illain, llol.llrtt'I 7 ) Sind,rom,ul ,i ilertrand, (1933) Bau sindromul posterior aI calotei (Sohotl ' ll,6?) se cara,ctcrizeezi, lrin aparitia unor mioclonii velopalato-fal'ingi0ll('' rrtlcscalimitate tloar Ia nivclul vilului palatului (',nistftgmus a1 r':"r"hrhli"), r[lr susceptibile si, se ext'ind[ !i po mufc]rii felei qi/sari ai lncrnlx'nllli sr perior fschott, 196?; Popoviciu qi colab., 1.973' 1980; Popovitirr 6i I'rlscu, 1981). ,semiologic lrtlrNl i $ ) Sindronnr,l,lui Gasperirti, cupriticle nn con1,cx1; lrrjt riintr-un cleficit al neriilor danielli' V' VI qi \rII rle o 1:altc, rriitx'iit't r rr hemianestezic contraleter'&l:t tcrmici, si durcroasii ('I'roncorti si l\'lottl,rttr:tli, 1960). ,li lost c).prlsc dc noi llnl,cliot lir !) O.ltalm,oplagiilei,nlertt'1t'clettre oolrlor)lotorji. sistemclol 1rrr,l;ologia O) Sirulntu.trn'Lcpetl,nn<ttlure (nte;c tr,eltr,lice,): pr.',r'rr'nttt],'iatt, utrtlt'r'1, I ) iJ'intltou,u,l.ltti lfr:Jxr, si.ndrunnt['Ttr u,nr:u'lctt' sILpo'iorLrii' d,( ?itJiat pttl,tr,naufttr (srr,tr, htrniTrlallia (Ll,(t'i1.i1' rl,totrtr.t,l, i n ) At\ ' prrtitlizir, il)silltl,orillii, lil no it 1[ Il[-lt cllro iz('rr,zir, rr,t'il,ct(ff lrlitrh'"o Ir'rtt'ltii ' .tooilr,zi1, pctt'r'llii ltt'tt tiltllgirr ('{)lllrtthll,{rt:tlii,..l'a,t:tlizirl, o ltort ti;tit,t'ozii, stt,tt :r ptorltttiii, liIrt'r'krl tIttIitIrtl,oillliilir,n plt,r'{irr,lii llI r,stxr 1i r,itcsl,rr lrtitLllzittttlit, lonttrl, itr {t'rtilllul lttr pt'itrltir,iot'ttl tttt'zt'ttt't'frllir'. rxltrlrr,tultti r,lc rrurt,ol lir,rr,, | :t'i

, \r'rrl l l r , r ilaI i/ , r ir r r r r l r l l r/rr' l rr.l rrrrr,rl rl rrr' n l i u l t{ r, si utl nntu.l \l thtt' l)t t)t it l)cr(r(:hii lIr , trnrlitntlttl itr. lt'11tnrttlu.l I )| tI | | |t t ' t| | t t t . r'tt prttlllizit: 1,o1;itlii r p l rs?i . rl rrl l l rl i i r lr , lic il nr { r i, o li l l rrtc trrIrl r' Io r' IIi ' l ,i rftrtio

\\ r'blr'", ltlirr alcvlism localizatle iilturr' lixisiii si ,,lirlsesintlurattto posterioare'p(r al't{ttil irlr'i,irrl,olrri, in r.eciniit:ltcil lulor'(]i crre,b]ale 'rrlol .orrrrrrrir.irrrl,i, pirsterioari,, care complimi in rnod dlect nervul IlIr pli'r rrrrrsi lrir.iotttl poduncular (Ileadorvs, 1951). ropu (sau, sindroanzeleltedu,ncu'ln'edorsule) :! ) Nirult'oameletrucleu,Itr,i rl,I i rrsI fol sistetnatizate(Loeb si lfeyer, 1965 ; Bodechtel 1965; Popoviciu 1rr ;,rr lolrrl r.. l9S0; Popol.iciuqi Pascu, 1980): qj ,\ ind rot.ntele royw: i.nferi.oare ule rLttaleului l'u,i,Claude-Laye?j ("'(u silldromul lui Xothnagel ttt Ni'nrlronrul ) se r ,rr':rr'1 priritr-o paralizie pzrrlialii ft oculomotorului comun cle rrlizrrrirz,-r de partea prrr'lr.rr lrrzirrrrii ;i lrrin tulbrrr:ir'i extrapiramidale ;i cerebeloase
r' lrlli: 1.

l{)(iliI rolnnii Ii/sr,u rrrrrlisrro (Aqgin,tr 1rl(irrot,ico ,,si Vrriu,,11)l-rl3; l.)01xrvioiu, l'rtyrviciu f i -^Dgiil,r, 19ii8; Aflgilur li cola,b., 1975 I l'opovi0itt i1i coltlt., 1980). II) Afecliun,ile inJec,lioase s'i imunoalergice d,etntnah,i cercbral (polfur\tcirfitlitels de tip inferior sau superior, rombcncefalitele, sclorozr rnull,iyrli"l, qi afecliunile demielinizante inmdito) produc variate tablouri srrniologice, cu configuraiii variabile, complexe, de lcziune a norvilol orlrriolri, rle cele mai mult ori nesistcmatizate. III) Bolikt eredoilegeneratinte .:i d,egenerative implioS, do ascnrcll{ll, k'ziuni ale nen'ilor cra,nieni. A) S-a conturat incleosebi entitatea clinici denumitS, paral,izie lt . lr.r,rd, Ttrogresirti (P. B. P) a adultului, care realweazd,r'tn contexi Bemiologio crr:ifectarea ilegernerativi, a neuronilor motori din trunchiul cerobl'l|,l, lrl |Jpecial ai ultilnii{)r neryi emnieni (do Ia perechea a Y-a la perechea a XfI-rr,). .,\celsii, P.B.I' I'eprezintd, doar un $inahom in cadrul unor variato lxrli r)curologice. In tonrte raro cazuri, P.B.P apare in mod singular, oil oonsfituind cle cele rnai multe ori o modalitate cle debut a acestei sufcrinlo rroulologice. ln cadrul P.B.P: unii autori inclual qi aspectele serniologioo din scleroza lateral5. amiotroficd, (Norris gi Kurland, 1969). Contexl settrioluoie Cele mai multc ;azuri tlebuteazd, cu tulbuldri de vorbirc (clificu ll')l,t, i de fohalie, in special cu rinolalie), Apoi se asociazS, dificultd,l,i in doglui,i{ia lichiclelor lsi a solidelor, atrofii faciomasticatorii, faseiculalii po linrbil, ;i pe muqchii rnaseteri qi tulburi,ri ile masticalie. Iieflexul faringin,n rlisp:lr'e la multe cazuri in plimele faze ale bolii (Bonduelle, 1965 ; (iirho qi Kovarik, 1970). In alte cazuri, imediat clupi elebut, s-au inst;aluh 1,ul buriri de respiratie, uneori gr&yo (Black gi llyatt, 19?1 ; Castaigrx) {i colab., 1971). Completa paralizie a mu$culaturii masticaliei duce la dl,rlorr rr r, rnandibulei, iar afectarea orbiculaluldi buzelor pelmito scurgereasalivei rlirr gura intredeschisai,'Asocierea aproape constant5, a tulburlrilor dc doglutilie duee la acumularea salivei, alind impresia unei hipersalivalii. Palatul noale devine imobil qi aton, pemitincl regurgitarea fluirlokrr: pe nas. TulburXrile de deglutilie sint frecvente, ceeace face necesartrirrl,rorlucerea unei sonde nazogastrice. Bolul alimentar sau lichiilele Du pot fi l'c!,inute de citre buze, iar gura nu poate fi suficient de bine inchisX,. ltolrravul este, de asemenea,in imposibilitatea de a impinge cu limba alinlontcle in fariDge, motiv pentru care t^z^ reflcxS, a rleglutiliei nu poato {i rleclanFatd. Bolaavii se ineaci uqor cu alimentele. I)iza,rtria este frecyenti, $i evolueazi, rapid pinii lzu anar[rie. Ao|ul soapir,prin nas in timpul fonaliei, iar corziie vocalo sint in pozilie &nol'rnali,. Dificultii,!,ile iniliale in vorbire sint proclusede hipomobilitatoa limbii, Ll ca,r'ese atiaugii, paralizia pa,latului moalo. Bolnavii n[ pot pro]rur|,lr, rolect lingualelc, tirnblul vocii captrt5,o tona,litatc nazalX t;i dispa,rornorhth,tiu, vocii. l,ipsrr,clo inchiiloro contpletl zr,glolci, palalizia, mrrsorrlai,rr rii t'iit'iLralo tosl)irr11,io buzclor', cit;i i,ulbLr cornplotanzii tftbloul serrriuloilio tlo vot'lritr:in I.r,l!.11. rr,ltulbrrrtrrilot' Atrofiilo ttluscrrlrrlotirrl' plozrrnto rJi vizibitc. lrirrrb;r, osl,o Iltrsorl,, r lin irrrobilil, ll,rof icit,. llo irrrrrrrrrrrrrr, irrcrl, prirnolo [rr,zo lrlo lrolii, $irrtrnrrrrrltr ryi tttrtryoltilrtt tn:t,url,r,,ti, lrlclil'ot t'r,lirrl'r rrlrolilt, Ll oxrlrttotrttl sl,rr,l.io 4i lu *l,rlngol: ! t )
| 11

It1 flitulronul hti .Ilenad,il;t, asemSnltor cu plecedentult se manifest[ 1r'ir lrrrlrrlizirrotrulotnotolulti comun de partea leziunii qi prin hemiparezi, .i rrri,'iili inrl)lrlntare (de tip coreic, parkinsoniene qi intenlionale, aclesea r'lrirrlrrrirr.lorrii ;i tuioritrnii) de partea opusal. roptt: ale nlr,clewlui l',| sinr|rorttt:I.t s1.t?erio{Lre :t1 Sittdronul lai CltiraE-7'oir-[icolercu se caractedzeazd,prin hipel' ( irrczii rl ir.r,r'st,,rigiditate extrapiramiclal5,, herniataxie, disdiaclocochinezir', prlr.r.rrrn si priu hemiparezir,toate 1l hemicorpul contralateral leziunii rrr, li.rlrri r',r1u $i {la care se poaie asociafi o leziune discrti pir"amitlald, rr;.orrr',, lullrr ri}i dc sensibilitate, respectirrult sind]om talamic, care sin1, lrrr.rrlizrrlc rlc nsernenca ilc partea opusi,. It1 triurltrtrn,ul ltti Niaolesctt,este asemiinai,tor cu precedentulr dn', rlrlorilri lrplrrlui tri leziunea est situati, inapoia nucleului rogu, poate fi rli'r'lrrlrr i,r i ilrv.rrsrr ! iu'hLiWclnekinli ;i, ca atarc, se produc milciili invoL[n'

l :r tr' l r illrI llt r lr . . il I in rlr'rr.ttt.do lctltnultQle cu]rrind mai multe grupe de sintlroamtr (l ,rrcl r ii . \ l11 r ' r ' , ll) ( ii r I l J o p o v i c i n ti c o 1 a b .] 1 9 ?2' 1973, 1976' 1980; P optl t i l i rr i: i l' r r s r lt , 19 8 0 ) : sllperioare se calacierizctzX, selniot) '\inrl'rrtnrLtlflrlerai cefebela{1se lrrllrr'. lrlirr rri;rr,ritrcctcbclorlsfl homolatcraH, $i prin hipo- sau anestezio ilitelile )t s,eqsib rlrrrr.rrrlir, lr.r'rrxr-a,lgezicil (sau un"eori pentlu toate |'r'||IlrIlrrI(,r'llit. Sc poate rsocizt lrtl sindrom Claucle Bernard-Ifsrner iDsilrrlrlirl, o pirlrllizie a, percchii a IY-.r, contralaterall, datoritd incmcild,t'ii lrlrrr,lri lriiclicLLlni qil uneori, chi&r o hi?oacuzie sau surditate (clatotil;r'i l r.zi rr rrli r r olir r r r lr r lu i n l e ri o r). lt) N iniromul,tU norinau'il tr:riluce o leziune 1a nivelul eoliculului rirr1rllirrt', rtspectil' r regiuuii a.nterioare a tuberculilor quadrigemeni l1i plil palaliZi:,t milciuilor (le ridicnre qi/sau de coborire Ill(r rrr, nrrrrrilcsi.rj, rrr'lriLrr',rrrlt,sciits,rtiialt' cu o par:llizit do colYclgenli,t cu o midriaz5, ptllttlriicri ;i orr tl u,bolite rl reflexelor ?tpilare. oJ Sirulroutul lui l{esxenbau,tl realil'earn un cont\t clinic constil,ui1, rlirrlr'.rirr siurllorn .|.'aliuilud, Ll crtrc so asociazi['; 1)islitgmug disjunotiv' rrrirx,hrrriioc rtkr- t ol,r'a,clo tii, l ttlbnlilli pupililrt ,,sipaleze izolote (lo ntlr.vi I I I ;i I V. 1,)strr rut sitttlurrri de suft'rinlli il substrr"n{cicenufii porirp()duot,rll(! Ltrt'ttlor' Iorrgit,urlitlt,loltosl,ct irtilto, ptitr protr'.te oalutir:tt ztlt',:t,t rii rr,IrrrrrtIr,Ir,Ici i tl sttl i rrl o tr' ,ttr,trtl rtrti Lr,i trttrt , p rrrl i c ttl i rl tl i p l rrl trlr r i lx x lt ' t ior " r r ' t l x{ l i orrl l l l tl i Iti 1x' tp l i i r y trtr' * r i u ,l ttl i ru rs l q i , r ' i t l tl i t' tt' , xtr IrII l tsrtt' i l t, r'r,r r r r i r,t l rrrrr r r r r iiI r r r l :l tl

T
l ,rt rl i tt f ilor ' , r . s il r lc rrrrrl i c o ri r,l l l r . f.l l o l rro rrl ci tl orl l rsl oi rl j l l l rrl ;i l ,r' l rl l rrzrrl l ;r.rtl l o lilz li, t t t ir iiir z i rr i rr r,rrr' ' rrrl r.trrl l { i c i l ro l ii . [.]rrtroti l ]al l tl i zi i l , qi l l 1,roIi rr, :tcr,sl , ot ' t t r r r f c lr ilr u p o n rL i l l ro l rl rv i l o l s i ;i l i rli co cl rpul tl tci t cu aj ul ,ol l l l rrriirrilor'..llrrscit-rulirliilcrrpa,t prr Iirrrbi, }r tulseteri $i urr0or.iii pe musculatu| rI llu I l ( 1 1 t .

S l,r rlescris tulburili ale motilitiiiii esofagiene li gastlointostinal(j {lirrrrlucllc, t965; Boutiin qi colab., 1971), precum qi tulburlri cardiaco i trlr Iiovrlscrrlare. Tulbut'ilile respiratorii pot fi cauzate de pareze al(l rrrrrsorrlirlurii lt:spiral,orii,de para,lizii ale corzilor vocale [i chiar de crizo lcslrilrrlolii centrale (Carala$li colab., 1966). l)(lgcneratea ciiiior corticobulbir,re, relativ rar intilnitii in P.B.P purir,, ;rrlrrugr'i t'lcrncntesemiologiccde paralizie pseudobulbad. l,.,eziunile centliLrl vr'11r,tliivi duc frec\.ent la tulburdri circulatorii gi respiratorii foartc
ul it v{' '

iladrc nozologiee 1) Paralizia bu,lbard, progresiril crotui.cdla adolescenli qi la adul{i ;xrirl,orp[rea fie ca, Jorntd sptoratlicdrlie ca Jormd,eredo-familiald. (Colmant, ll)?it ; Malkland qi DaIy, 1972). Diagnosticul cle P.B.l' puld poate f i st.rrlrilil;numai pdn examenul anatomopatologic, care va erolude leziunil{, pilir,rnidale, P.B.P apflrut5, in ailolescenld,a {ost consider.ttii ite Marklanr I li I ralv (19?2) ca o form5, particuiar5, a bolii Kugelberg-Welander. :!) Grw)ul sclermelor lateral.e amiotrofiod (S.I'.A.) cuprindo 3 tipuri lrt itrrripalo,in ca.rcP.B.P apale fie la debut, fie in cursul eyolutioi (Hirano ri rurlub.,1967; Brotly f i cota;b., 1971). .r,\ !l'i1tul sporudic al B.L,A. cuprinale cortextul clinic de P.IJ.P in cel o/o din cazuri (Nishigaki, 1970; L972; }Iiiller-Jensen Fi Be1'nhardt, 1ru {,irrlii ll)7;t). I,'r(.{,vrr1,a P.B.P in eadrul acstor forrne sporadice de S.L.A. es1;o rrrri rrrarrr la biirbatj decit la lemei (Girke qi Kovarik, 1970; Rai qi Jolly, l1)?1 ; .Nishigakir1972). S-a raportat o creqterein ultimii ani a, frecvn1ei irnnoi bulbare fa!d, de forma spinal-d, a S.L.A., indeosebi in jurul qi pestc vhslolc rlc 50 ile ani (Dazzi gi colal:. 1969; Campbell, 1965; Sahar lllrr t r , 19 69 ).

lr) f ipul ,rd,eGuamt' reprezint;, o asociere intro S.I-,.A,, parkinsorrisrrr1i rlcrncnfi,. Tipul ,,de Guam"'prezinti mai frecvent sernne bulbaro 11i riyrrrsl irrilirle<lrcit forna sporadicfide S.L.A. Tipul ,,de Guamrt are o evohr(irr rrrri k'n1t1decit celela]teformc (Ilirano qi colab., 196?). l,'ol'rn(r dt) S.L.A. asemdn[toarecu cele ,,de.Guam"seintilnesc, se pare, r1iirr l,)rrropl.Nu s-a putut insi preciza nici un factor ereditar, nici subIr':rIrrl irrfcclios plintr-un virus lent (Gibbs qi Gajctusek,1972), deqi so prrrrr cii uilt, multe ozuli cu sindromde S.L,.A.realmentevirotice (Popoviciu :r I'rrrr:u, 1.980). It,rlalil tliltre complexul parkinsotrism-demenli, si S.fl.A. s-a velilitrrl lrr l5-2io,( din cazuri (Brady ;i eo1ab.,1971), f:r,pl. ronfirmat 5i do :rllii ((lrrlrl;r;si col a,b., 1966; Bonduellc si mlalr., 196E; llla,it 6i cohb., lt?lt). c,) 'l'iytrl tril,ilar tle iS.7,...| ., r.lesttl rlrr lar', plczirrlii u l rarrsrnisjrrrro :r,ulosorrllldourinlmtl, ia,r scrnnolebulbalo sint tnai frecvenl,()((1as1;lr,igrrrr ri colirlr.,l1)70I .llilrr,tro J067; Ilrrglrtrs ;i r:oltrb., [i Jol]r]m{!,11170). il) I\tuli: itr, hnllttrni,lttolyninti, tlitt, uytr,-tisrkt ,,t |.nt,l.i i rttu.xr,ttlurt
l: l{ l .d

t) tllntlit rtttrstulurirpittuli in.lutlilii (lnxr.lrr. ltr.i ll trrl.niqIlo.llurtnt) , tt tlclt'ttniltistttgcttr,l ic (trlri trlrrsrrrrosivirrri,osurrurl) irriurli rlr, s(r l)oirl,r' llzirrrri lrtrlllllt'o( l ) t'rr,chtnlLrr ,,siVrrstr,ll:r, li Illlnli{fr, 1001I M rrrncrrl,hrr,lrrr' llli0). r\('o!li col)ii, incii rlo Lr rllstrrlc, lr\)zirLl;itl,rrlbrrri'r,r'i rlc xrrpl 1i rlr, rllglrrli(ic, alr url filcics irrtrxltlcsiv, rntrxlibulil csto ciizrrlii,lirrrllr lr,l lolilrr ,r trrflcxclc lmllta,r'e dirnimtll,c. Oclo rnai rnu]bc cazuli rlccrrlcrrziiirr lrrirrrul :rrrrle v ia!,ii,. ltr forrrLcle rua,illcniglc, cu supnrvie!uiro pirrir,irr rrrloicsr,r'rr i , I rrlbuliirilc bulbalc pol, fi intilnil,e pin5,lzr, douii,tlcitni (li rr olz u li ( Nlu l ln l 'r r colrr,b., 1969; Ilriul f i ltrnofy, 1{}71). q ll:tlrrnthr) ltl Atrotia nyuscu,lu,rd, tpinulii juaenild ( boala l{,u11r:lltu l otntctelizeazd, prir) |l,ttofii spiuale proximale pseuilomioprbiccr,iillr. rrrr ,1,,1(.nninism gonetic autosornalrecesiv (Srrith qi Patel, .l.t)65 I l,'rrrlkrrrr r,ollb., 1969; Namb* fi colah.,1969). ExistL $i cazui slor',r(li(l(,. lrrlrli ,rrrrir,Ileryilol(franieni(inclusiv bulbari) a putut fi demonsl,r'ltI, lrl :.i1,'i;, rlrrr crrzrri {,\{eadowsqi colab., 1969; Narnba li co}ab., 190{,r. a) Atrofia musculard, spinald,lo,rd,iM(boala Yulpian- llcll hrrlr l l,) ;rlr. zitrlr'i, un dcterrnitism genetic de tip autosomaltlomina[1.,dlt,rsirrl ,sirrrrrllo , r,zrrrisporadice(Cazzator 1969; tr'rieil SiDmery, 1971 l Zellrvcgrrr';i('olrrb., llr72). Doar puline cazuri plezinti ,,si lczinni bulbare (Dyck iJi I rI|| rI I ) ' r'|,, ' llrl;,q; Bobowick $i Broaly, 19?3). ,1) P,B.P in alte boli degenerati,t:e. Dintre atecliunilc degerr.rirlir',, |lr (riue poate Si apar5,P.B.P, amintim: tu) Hi.potentitnea orlostalic.d,(sindromul Shy-Drager') s(r 0r|r,olr,r I z|rtzii in plimul rind plin lipsa transpiraliei, rnanifesti,fi sirrrrPrrk,,pir.r' ,llrr.ll controlului sfiloterelor', sindrom palkinsonian, atrrrir.,ri sr.rrrrr,. lrrrlllrlt'. lt) Sirtlrotttrl Riley-Day este plotlus de o ('legcllerarc rr lirlrrrrr(ir,r t , l iculare a bulbrrlti, cu inl eresaLea qi a newilor bull:ar'i (Ilrtrurislcr',I l)i l ). c) P.B.P asociatd,ou surd,itate $i. cu abo.fie opticd. losL rlr.ro is:i rlr. rrrli mulfi autori, f6rd, a se putoa contur.a un sindrom ^apaltc (il'r'ilk'l 1i colllr., {?0; Boudin qi co1ab., 1971 ; Serr.atrice fi Gastaut, .11)7il). tf) P.B.P asociaid,corcei cronit:e Ilurttittgtol cste litrli (lrnrli rjr Vrrin, 19?3). o) P.B.P asoci,atd, sindromului Bteele-Richardson-Olsaewsk i u, lirsl, r'r.rrr:rrr,l1ii chiar tiin articolul pfinceps al acestol autori (1964)li (l()lrfilnrrlri, ,1,' l.|.hrrn:rnn si colab. (1969);i Constantinidis colab., (Jt)?{}). Astn.l, $i 1',' lirrgii selrlele cuntrsrute t1e acestui sindlom, au fost des(rriso llr lorrrlr. r,||rltl' r.uzlr|i .i tulburdri tle tlcgluli{i,.. nL afectareo, altor sisterne; nucleii nrlzt'rrcr,lrlili 'iJ P.B.P d,sociatd. t IiorrrIrrt.IIt.ri colab., 19?0l, talamusul (Van Bogaert Si oolrrl,., [Xifi), (1,t(, r"'lrl (\':rrrJJogaer't;icolab.,J965; tsrbwnellqi cotati.,tOfO;. !) I'.tj.P a*ociald bolilor paraneoplazice ale siste.ilu.lu,i turtttr. l'.1\.1, rtr tottltlitul umri sintlom tlc sclelozii lateriLlili, amiol,lrliit,ii rrirlrrr,,oltrrzr,, rr losl tlrsctiir in cillcinoa,moblonhopulnronarc ;i allr, 1itrl r.i rlt, til,r,'r'r rrnligtrr, (lllrrirr qi coLlb., 1{}(i5; (iolline qi S'rxrlst,1 , ii)0?; Nor.r.irr 1i r"olllr.. l lXi9). ll\ ,\iri qt,hrlltiu .si sr./r'lota ltrlrt(l u,tttiulto,/irrrr pol rr.lrlizrr, l(,ziuni rrrrrllilrlr..r'orrrIIirrrrIr', rrL' trllt ikrl, r,rrrrrir.rri lrrillrlrri 1i porrl,ili, ICtrlo rrrlx[lirrrl rl(.r{.1ilt l (tiiur,r', llt,':i) r.r'i irr lrrtzr,rr{lr rrrrrri i.l i IrrI r,rrI rr rlo lIrllrli

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p-iimetor segrnenrc j:i':lig $il.or9r1ial gi fald de com-prosiunile cewicale-9i {uo.r)ulDurur, cal.eartrg-neaz6 adeseatulburxri paretjee Ei atrofiee Elos<iruur)gol|,rlngee(boala I:9tt inalta, .tumori ale giurii oceipitale, iumori llrl ltmedu laro tnalte, glioze mie)o-bulbare,pachimeningiti hip'ertrofied cetljcalcinalte E.a.). afecliuredesrulde l,ar.i,cauzal d"de o , -, t') lnyJqlo1ati.a .lui-fVprnickr, tloliciant[,_ de thiamina,(de obicei ]a alcoolicii eronici), asociazA, o oftalfii{i. I otalS), o ala.:i ic si demenfi, progrcsi.r.d (Vicl,or qi colab., I,.lr:qio .(ldeyai J 071; Iilank gi colab.,1975).
lniduva cor-vioaH qi bulbul), ocle tloud, cauzo mdi I|('ovonro Illnd Bclerozalaterah a,miotrofici (inclusiv sindroamele de SIA) qi niringobulbia. In. aceste-situalii se nai impune G*; sd; fa,cd, un aUgl

O.

PNOBLEME DE DIAGNOSTIC

IwpaRauzu

3,1 EXPLORAREA SEMIOLOGICA A DEFICITNLOR MOTONII E:plorarea seiniologic5,a tleficitelor motoxii (p&rezogl I&_ nrljzii sc faoe prin : 7,) Examina,re:| a,teutd a m,otititd,lii actiue (s a voluntare) ca,roroprozint:i ansamblul tle'nrlgc[ri pe czre un individ Ie oiecutd,in motl vohtntnr, incepinalde la nivelul celulelor giganto-piramidal'o ale lui Setz dln cor. l,oxulprerolandic qi pin5, Ia nivelul muschilor striali, care Blnt axocutorll dilecli qi nemijlocilj iri miqcirii. Se procedeazS, tottleauna Ia ca:atninurt, not,ili,td,liiactit;asegmentara, adicd, invitind pacientul sd,execute tn nurd sistomatictoate miqeirile fiziologice,alin toato ar"ticulagiile, obsol'vlntlu,ro {1uatontio amplitudinea, rapiditatea qi precizia executdrii lor. 2) Tottleauna acest examen se comptleteaad, au: a) aag oraraa,fotlai nnnculare segmgnlure}. b) probele speciak pentru depietarua pareaalot (lrobele lui Band, llingazzini; .Gr4sset,Vasilescu, Ba,rr6 -Iiohuror); u\ enarnenul, (bipeda,uniperld, pe virfuri qi po c{,lciio); staliunii ortostatice rl) euam,enul mersul,ui, al saltulwi, unipeil pi al Jugii; e\ eaptlorarea molilildlii ytutiaa(a tonusulbi muscular); t) enplorareamotil,itdlii.dutomata i g) ertid,enliereaet;enlualelor mifcdli, si,ncinetioe; h) eoid,enlderea a:anhtalelor ni.ycrlr I inrclunlarc, 3 ) Semnele asoaiate sint deosebit ale importante pentul. diagn.oatlaul, lopograliaal paraliziilor: a) atrofia muscularf, importantit $i progrosivd, ilno{itX de modificfui de excitabilitate electriod, inrlicd ils obicoi o lsziuno r! Trouronulnimotor periferic i b) nmdificdrile refloxelor ostoo-teud inoos6, $uta,nats,a,rticuliro Ei dccelaroaroflexolor patologice phamida,ls il do ,,olihoraro" (sinoinezii,rofloxo ds trip16,retrac{ie otc,) contribuio ln, treD, rt ,l,oadiagnosticului diferqnliial lntrs o leziuno do neuron motor coutlel poriforio, 8o,u 4 ) lluantenul, elcol,rioolaaia, emmenul, fr,M,Q,, paameai, oto aai. (lsu protiodsoinrlicnlli d0 dia,tsnortlo rfl(rrdo Ei alte euplordri newotiaiologioe littp gra{lo: lozlnno po ncruontrl r. otor' fi0ntru,lna,u por,lforlonl lo 0o nlvol, lsliun6 muBcIlor[,,tttlbrrrnr,o funollonul{,ol,(,,,).

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:1.,3.1.L2.Eemiplegi.a spinald este ipsilaterali,, intereseazi' numai rrrr.rrrIrlo|o, iar'leziunea medularS, este situa't5, cleasupra intumescenlei .'r'r'iolt,lo. l)c cele mai multe ori hemiplegia spinal5, este asociati, cu semne r,lirrilo r1ohemisecliune medulal5,: sindrorn Bro'n'n'S6quard. Nu se conrrlrrLri rrir:i urr semn de paralizie supra-medulari,, nici paralizie faciald,r nici :rlirzir, nioi dizartrie. Ilemiplegia se instaleazi, f6rf, ictus $i fd,rd nici o :rll.r'rrrr a, stirii de constienli,. Se recunosc cu u$urin![ e]ementele senziLivrr lhr sindromului Brown-S6quartl : abolhea sensibilitSrilor profunde rlc prrltul hemiplegic[' gi hemianestezie termo-algezicS, ale partea opusr,. Nrr rrrrri pot fi utile in stabilirea cliagnosticului de hemiplegie spinal5, ($i rrrr plirr lcziune emisfedcd,)tulburirile sfincteriene care de obicei nu lipsesc, plrrorrrn qi prezenl,a unor mici atrofii radiculare ale muqchilor scapulari qi :rlrr I nllrozului. flrrrniplegia spinalf pouta Ji' reut'izatd'de : :r) 'l'rrurnatisme. b) Mielite (virotice, luetice). c) SclerozS,multipld,. tl) liilirrgrrnielie. e) Tumori, care de multe ori realizeazi" de fapt o tetraplegie xpirrrr,lir,, tllr cu pretlominanli pe un hemicorp. f) Discopatie cervicald, (lirrr'l,o ra,r). g) Sinilromul lui Mills, tle etiologie necunoscuti incS,(probabil progresivd,, e1ectiv5,,a fasciculului piramiclal) so tra;rlirr rlrgcrrerescen!5, rlrrur priutr-o monoplegie inferioari (crurali,), care se extinde lent gi la rrrrrrnbml superior, reallzind o hemiplegie spinalS, f5,r5,tulburS,ri de sensi lrilil,ir,1,o. :1.i1.1.2. Paraplegia poale fi realizati atit de leziuni ale neuronrrlui rrol,or' rxrrrlrftl, cit qi de afecliuni a1encuronului motor periteric. Oa atare, rlirr rrrol,ivotlirlactice, in acest capitol vom aborda pe scurt pamplegiilo lrlirr lrziurri r1o neuronului motor central (cortico-spinal), care pot fi re:llrzirl,o rrl numai Ir nivel spinal (indeosebi),dar gi Ia orice nivel al lreYrnrrrlrri, rlrcr"r,sint interesate fibrele piramitlalo (ad.eseacu realizarea de l,.lr',r,plrrgii). Nr: vom permite ca in continuare s5,abordi,m separat problorrrr,lr rkr rlitguostic topografic qi etiopatogedc ale paraplegiilor in sensul (atit piramidale, cit qi periferice). rrl rlrrl'itril.iei lrrr';1 l) I't,ntp[egl,u spinald,. Forma cetu mai caractelistici este realizatii rlrr iririrllornul de sectiune ttansvers'i,, care intruneqte o para'plegie cu insolit5, tle anesteziepentru toate modurile ale sensirrlrrrrrr, trilrr,rnirlir,Ie, lrilii,.rlo,plroLrmSi de tulbuli,ri vegetative qi trolice, cu neti, limitale snbprin apreciereamodilrrziorrrL'r,. Nivcltl leziunii me:lulare se poate preciz2r, l'iciiliIrl rrrllorolor qi l nivclttltri trrlbtrdrilor rle sensibilitate ;i, in rnrtrl olrligirl,orirr,plitt crrrrnonul l./.0.1i. tli prin rndiogr:r,fiiio $implo Ii prin rlo rurni;trr,sI,. lrrrl,orlrr (simiLt,t'o lli rlo lrrrrrplogio spiltrr,lii srxt{iuniitt'rlnsvot'so) '|'ir,Irlrrrlikr 1tol, tultnltt'rrsitttti In(nlulrlro, tnirrlil,c, lroli rlt' crrl6 tnr,i vrrliitt;rt lrrrrlizrr,l,rr llt'oottsc: rlrrrlirrlitrizrrttlrr, lroli r lcgcttot';t'1ivr, 1. tt,. t: l A

vIti'rtIttIittt'(ot'Itt pt'irrstlltti.tt{rr !) J.'uxt,1tl,r'uitt lritlittri lroitlrrli plrrtlttsii llt'olol rtL' sislltttttlttivtrtttlrlrl-ltltzilitt), zir at'iololorplllattttttlillttc i)tr)(1('s(r lr' ;. rt. mativo care comprimL pittirit'ttlporttin, boli tlernit,linizrtn ' 3l Purapleeia paraunl'rald este reznlt.r,l,ullc'ziutiilot' I ti I It'I Irt It Ir' :'ll tromlrolkrhilri tlt' sittrtr lobuftui paiacintrdl (meningioameparasagita'le, lonEituclinal, sindroame bilaterale ale suferinlii a altelelot (j('l!fl)I'iIl(| itI| | ('r'i oar'6etc.). Este important de relinut faptul cd' dcficitul trtolrtt' lrtrt lr' l'i precetlat sau inso-tit de crize jaksonielle loca izate Ia nrt'rrtlt('l| ittiirtiorltr', de tulburf,,ri sfincteriene. 'lrecum $i txrt('prin leatuni nt'ultiple.In atelo- $i al'ttli{)s('li'r!tzrr 4l Parapteqtopot t'tt a,fecta, ischemicS, de clezintegrare brali,,'multiflel"e hlune ltrtrciirltrtrr fibrele corticoslinale ale membrelor inferioare la nivelul cmisli'rrrltl cllrr brale (centrii dvaii, capsuia interrri,) sau in trunchiul. ccrobtrl, Irrlt'lizlttrl t istt ttr paraplegii sau tetraplegii (cu predominenll pl raplegiei). Pfi n t ttrrtrrt'r prin ]eziuni multiple din sclororll llr plii('i' iimil-arJse realizeazfi p:r,raplegi1le din unele encefalo-mielite, din boala lui Little q. a. lin sindnnnr lo topogralicSi eliop&Iogenia 3.3.1.3.Problemed,ediagnostic paraplegice, In diagnosticlt'l sind,romuhti parapleg'ic este necesar sL so I),rtrrrrlgr'i in mod logic $i succesiYurlf,5.toareleetape (Riser' 1952 ; -$ollcirrrr ll){i?; ' Bodechtel;1965) : a) diagnosticul tlifercn.tialintre o paraplegi(' rii {r.,11rr1,'rl doparaplegie"; b) diagnosticul de tip al paraplegiei (piramidalil ; tlrr ttltt ron motoi peiiferic; pedcadon:lla' poliradiculoncvriticd, . polittrrv.t'ili|l ; rnusculilri) ;-c) tliagnoslicul dc nivel irr crzul paraplegiei pillrttirlrrlrr (rpi rtald qi topografia acesteia; cerebralal); d) tliagnosticul etiopttl rtgclt it" Yor fi eliminato in plima et:tpii it tlirrgttoslilrt 1l Pseu,il.oparaplegiile :l) Pseutloparaplegiiieprin artrite acute sau clonicc qi tr)lirr rrlllorr\ l'r tlAr|ri' protLucfalse dAficite rnotorii plin anchilozd,;i prin imobilizrlr'('ir'rr ul)t)||(|iIiIit poliartdta c\-olutili) cronicil poliarticular acut, {rtumatismul :rrrcllilopoieiici,, artroglipoza congenitalil, rnultipif,, coxNrNlt)z"lt' f. :t ); rttitti l.tilrrrlo cu pril carc clolucllzri afec.tiuni b) Psetttoparaplegiile silttltttrrtrtt' rrii, cu ltaxie gi/sau cu tulburiri t1eechilibm (ata;ie 1'rrl-rclit'ii, rirr r{ uluirnelnice, erodoataxii spilo-cerebe}oase'sindrollntl 1,cs(ilrrll;rrrr, rllorrme cerebeloase, al,axia frontal[ a lui l]rrrns) ; plin tulburili psihice : t,pirtrrplr'g..irr " rsllt'ilrr I . tr) Pseudoparaplegiile
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+r'rrziiir(scrrrlrr'lr. r':rrlir,rr grr,lilirr.ic lr 1rloIorrr.rrlrrrrrrIrri r.,i i, lr,rtllrrrrluitrtill,otl


I r r t t l r , r 'i | , i c r r ) l tti n ttr l tz{ Ir r {fr r l l l l l t' tttl r Itt|:ttr ',

i l ( , 1 1 1 ,r l r l l d 0 o b i t't'i n t' r 'o ttt'Ii Itti I i tt ( i i t'vr t zi l t', p ttl i tttl l |l r l i zi l l r i r t,l ( 'tt |,r 'o l tt( i 0 r tstIttr l Il ti r l ) i {( 'l l l ttr 'l {'tl t' l |,zl ttttI P l | g i i s r t t t l ,e t't'l t,p l 0 gii ( :r ,r l t's0 l r

t 31l

ttri(irrllritrrplcgii,lrl)oi ilr r'\{'llll'i(rt c) l\l itrrl,irtt.[ntt t t,tiltlr l' rl tr.rrlrrrr lol,r'r t lr\rzrlrlir rtrol,otii,ttrllico 1i vt,iJrrl,itlivtt, r,Ilrrgiir(1ll rrit,r'i LttIIrrrtrr,t rrrlr,lrnr rrr cvoltLtica,st:otttlrrnlri lji r,trrrlr.riir,r'cli1i iInclvil()r'clltlli('i.iJ{)llLll(t1f ,lrr lrrzirrnotrcylaxiu,Li (irrrltrosolri pilarnidale) Iipscsc..\Ioclilii iirilo irr,rrrrLclc l.li. sirrl, cl,r'actcrisi,ico. rrr 1,.( tl) l'olk nieli,ta,&cut{i e ltri. II ei.neMetlin intli, totdeauna in cliscu{io lrr rtlr copil s:l,rtIa nn indilid ti[5r, mai ales dacai,s-an conse]l]11:r,t sclnno, 1rllrrrorri1,olii infec{ioase (febr5, manifest5,ri digesljiye $i/sau respiratot'ii 'rll,clrrrlrr, goneralc), algii poriferice, ce{alee,ytlsi,turi, radiculalgii, str:i,r'ii .rlgii rrrrcl,h:, fa lialgii, semne meningeale (subiective gi/sau obiective). | 'rrlrrlrlr{iir, loate ti dintr-odati' masivd,, hipoton:i (,,paraliz izr, de dimileairr') rlcsclisi de West), cu reflexe abolite, sau sepoate instala doar o monolrl,'{ic, cventual paralizii parcelare. De ^obiceifenomenele generale qi meninu( rl(i l)r'ecod partrliziile cu 3-5 zile. In unele situalii, pierdelea blutali,, rllrrrrrrl,icii,, a fortei musculareeste impoftanti, qi ertins5,, atingind mu;chii rr.rlurilor', i:r,i trunchiului, ai membtelot, cu extensie chiar la nivelul mugchilol irrrrlvrll,i de pericarionii bulbopontini. Atlofia rnuscularS, este precoco si irrrrortantd,. q N euromielitn optiad, ( oftalmoneuromielita, boala l,u,i Deuic) debaji,rlo obicei brutal, de multe ori paraplegia precedind semnelede nevriti I rrrr,z opl,irii,(Dri,ginescu qi colab., 1962, 1963). in pliici acutrit l') Ilxistd gi cazuri ile scleroad, , care realizenzd paraplegii (rrrrr hrtrrlplegii) dramatice, flasce sau spasmoalice, cu senrne plramidalo irnl)r)rl'lntc. Sint frecvente puseele de paraplegie acnti, in cursul evoluliei rrrrci scloloze in p15ci. Puseele evolutive de mielit5 in cursul unei gclerozo rrrrrll,iple pot sd, se declanqeze cu o ,,tragici brutalitate" (R5-":.fgP", pot realiza in contextul clinic malifest5,ri parag) A.lte encefalornielite ;rlrgicobrutale, I& care se asociazdqi semne suplaspiuale. \) Spond,ilita tuberculoasd (boala lui Pott) trebuie suspicionatii totrLrr,rrur, in liulrr unei paraplegii acute la un adolescent (indeosebi) sau Ia un rrrlull,. l)itgrrosticul este u$urat prin prezenla conira,ctudi dureroase ;i it, rlru'olii colornci, dar mai ales pdn evidenlierea ghibozitS,lii qi a altor semno rlrr plri,lrrrryilo vertebrald,. i) llr,nrtnu,I primi,tits rah,id,ian al ltti Ewing poate realiza o pa'raplegio lrrrl,rr,lj1, Lr, copii qi Lr, atlolescenli. Djagnosticul se verificS, prin imaginilo lrrrl ioglrr,[icr: plulifocale, in geocle, pludver"tebrale qi costale. tumori primiti,De se,usecurl.dare i,ntrarahid'iane,intra- sau extrn. .iI JLl,l,c rlrrlrr,lopot plorluce paraplegii acute gau cu ingtalare rapicl5,, precedato rrrlrnrrirrlo o sourtl periorLdfl tle rahialgie qi ciaudicalie spinal5,. lil l[t,n.in,go-mteli.ta sifiliti,aii a,euttiintfi, astS,ziprea puiit in discufio. l) Il telom,ataciile (rumolismen'tul, total, transaars li ranxolisrnentul ttpintl rnl,rtrior) pot realiza fie paraplegii, lie tetraplegii dramatice (Lazot' Ilrrlr. l l)?2). ill 8 intlroanzeleparaplegice ou insl,alare lant-progresiud, : t) f*:lerozn rnultipld, (S.l\[.) realizeazS,cel mai frecvent un ast)tnenolr, I'ir,lrlou sorrriologic, cu par:lparezd,-paraplegie spastic5, piramitlali evolul,ivil, (url rn:r,irl(losoi)ou puserrri). Iformele ou evolul,io lont progresivir,, liiirrl, qi.fi,rll rr,ltoscttrno mici r1i inoorto h mombrolo Buporioa,ro cu s{)rrrno lrrrrlorrrj rlo sclorrrzi, rnull,iplii lirlioii, rlosigLrr, nrrlrlrl-npirrirlo lrloblclno tlo rliul4rruslin rlilirrrr rrl,irr,l crt trtiolil,olo orotrico, ort cotrrplosittttilo tnrdttli.tt'o rri ou i!nrllrloi. 140

rll lrli,cl,it,lc;r, rlil,i,lrr llrr olrirr,i, ittnii, rrltttttt'ltt s1tit rr,lr., r.l,it.jrrlol srrlrcr,iotrro ttr 'itriLllitnc.lr ttcvlrrriltlrrlr,tr.lrirlilttziutttlr' r,rr n,,irrrrr, ri ri rrrri rIIr Irr 1 -l.zirrrrii, cltt'ltt'lrrrtso, rrsooiiti'tr llr, rrtr'rrrltrr,lc, r,u sr,tntto trlltl,rr s.ir,., r,rr.uri\nr, vcslibrtlrtlo trr S..\I.Itr1otrt crtnlial potrlt tr i.liuglnosticu1 {'iilrrrrrltrsc tlo irrvi,sl,igrr,{,ii1, r,l.r, tico scljce, I[il| rlr ,i lill|s rljrr 1,.(j.1,]. trrrlir}e1,ice qi imunoe lectrofole rrrlrr0 rrlqrrrnerlte in plus pentru diagnostictl ,l, S.II., ilsr, cltlrr cr{o ru't.rriil:r, autoimuni rle aut9ag1gsi11l0 ;lstii,zisocotiti, ca o JJoaU, (l'clrrlro li ,lolvirr, ll):14 Liirventhll Ila.bat, 1957 li colah , 1960 ilrlrlsrlen 1i c'lu ir., I 15tt; ; ; I )nmii,qi cotab., 190-1, 1965 ; Schapira qi Palki 1961 ; Vari Surrrlr,,'I llri? ; l3r*usqi colab.,19i2, 19?9; Cojocaruli c,",Ja\,19?8;'Pop6viciu ryi t,rrr.rr, l$80; Kright, 197?; Colby qi colab.' 1977). montielila, boala lui, Dpuic) poir,t;o b) Neuromiellta opticd'( oJtftl , y()r f i o evolulie subacut-cronicii, x11 paraplirgic, rl.5i iir ?xlilllrrletic ..tlebut acu'l saLrsr-ibacut(Driig-nncscrr rn:ljoritatea situaliiior debuteazd, 1i coi:rlr., 1962. 1963). p.oru1'1egin cJ Mielita .cro,icii, spas t,-ttlicd, r:rt:d,oti.lili. .lueticd -(Er.b), tui GuiLlain ti Thion {asociotorlc s,.irrrr,, licd"u, lui XIarJun gi sin(lronr,ul de encefaliti, cil tabes qi.cu mieiitil Erb), frqiysnls altddatir, sirl .r lr.rrr r.te rar intil.nite astizi in practic,r,.neurologici,. Nu tr.ebuio i,Ohrqi rri lrr rLiti.m, iar prezenta sgmlului hii ArgyU-fi6bsrtson, a hipclcil,oz.i, rr lripefrlbuminozei qi po^zitiviratea rr,, -reactiilorB.W. si 5 benzoi r',r1rirlrr.l diagnoslicut. Tn plus. in pataplegia rpasmodici c1orl.-sitilit.i.r, '.lrrilici rr.lui Marian apar gi : keratiti,, tulburd,ri psihise importante (ca11,c1;r'r'irr,1r qi ,1,' tip demenfiall ;i, adeser. convulsii. de diver:e naturi (tumoralo sa,u ilrflrr.nr!r.J) Compresiunilemedwlare colii, primiiive sau metastatice, subdurale, extracluraLe sau intramoriu lllr.o) |eailiz.eaad,, in funclie,.de livelul acestora,_plraplegii sau tetrrrpkrgii. l,)rirr' 1,,rnj'i mulle pobibilitili de reaLizlrea dellsi[11[16e6o,' - O compresiune realizatS, brusc sau tapid se poate manitosl,rr,rrr.irr {r'-o paraplegie flascfi, ulterior, in decurs dd citevi s[pt5,mini, 0voiirlrrrl $pro o paraplegie spasticS,senzitivomotorie. Se intelege c5,tle obic.i I'rrzr1, ' (rrri ou dureri railiculo-funiculare intr-nn^terit'olil limitat, bine prociz^,1, stu bilateral) precedd,instalmea aleficitului motor cu citeia sil,,l,i,ririrri, Irrni, sau chiar ani, fenomen cu male valoar'e diagnostici. icil. - Alteori paraplegia esto lent-progreSiva, de la incerrut sDrrrt ,lrr de mu lte ori precedald, cu mult timp inahte de fenumenetlo clnurlicrrllri $pinal5, oel mai adesea fir5, clureri. - Alteori evolutia lent-progresivl nu esls precedati, de fonorncrtrr rlo rrl:urdicaliespinali, in scbimb pot apxrea 1y15iop11i sfinctoriene plnooor.. - Dvolulia cea mai tipicS, este unndtoaroa: mai intii faztr, rodlc'. LrrL ilureroas5,, apoj perioadi, de clauclica,lie,apoi sindrom Brown-sdqnrrlrl iLr shriit, paraplegie spa8tici,, inso!itd 5i rle tulburiri tlc scusibiiit.lt.o r..i, (r'rrrc tle mulLe ori Pot liPsi). rneilulara ceruicala superioare prorluc rnono- s^,ll h.rrrl. Compresi,uni,Ie plegie, urma,to r1e tetraplegie spasticS,, cu tulburd,ri de se.sibilit;,6 ,rr
lIlvet.

Compresi:,unila aeraicd'la inletrioare rea5zeazir, o paraplegio fiptrsl,l.ft - do hrlbul[,r'i pftreto-atroficotlc tip *idlcriin,r' rr.rrr. insol:itir, Bubju,cent5, Irrelo supoliotttrr (Llr- D')' 'i Oomptroaiunila nvdulara dmtalo ttti,,Lthaa,zi'i, 1r'oooc. 4ollioit. rnol,'rlt (1lt tIIttt;t,IttIttittt|tlttlrlt), (tlrr,1,0rilil lngrrstr'rlii (jI t ll. nlrnlifii,ll'iHi rrlorofloxolor.

l{tl ,fl

||irlorl |)| | ()| |ri | |i! |(. (rrrr t,irkrrr trr l' rIol{r'|| l|zirrtrii).Axl lrrl,tlt' ltirii, l0trlt'rrsr,rlirrl piklll, itr lrolrlrtoililrttik) Ll ttivrrlrrl lrlxlotrrittttLl l)tr, lrrz, trllcxolo crr1lt,tlt,l,o rrrrprrtiolrtc i ncr:r, rliu rni,ilooii r'ai,lnhl rlll(l\(ll(i outanato lrbd{)rninlllc 1trozonl,o, rii itrlirliorrro sint abolite. fu stititrtlr, irt compresiunile sub Du, r'cflt-rdo :r,|rrIlrrrirrIrlrr In cazul unei compresiuni sub l), r1itleaso mcnlin pii,strate. rirrl, r'1, Hoglrrorrtului Dro sepoate evidenlia semnul lui Beevor (itr1, de Arsoni ,,i lolrrlr., l1)?7): la ritlicarea capului $1a trunchiului, ombiJicul se deplarrorrzir, irr sLuir datoritd, laptului cd,porliunea superioard,a muqchiului ilrept rrlrrlorrrinal primeqte impulsuri motorii, in vreme ce porliunea inferiotr,r':i ( lrnn?resiu,ni,le med,ulare lombare suptaioare realizea,zn parapareze r|r' I i;r lrilurnidal, cu Bpasticitate (neobligatorii) qi cu unele indicalii de nivel. i\ltli.l, iu complesiunile I-.,1-L,2,reflexul cutanat abdominal inledol' esto prrrlrrl, ia,r'rtflexul rotulian (cu inchiclerela ltr-ln) este eriagerrlt.In lorrrplr.sirrttile Ll :rivelul Lu- la, a,tlt reflexul cutanat abdominal infelior r.rl r1i lr,llcxul ll,nal sint prezente, in schinb reflexul rotulia,n este alrolit. (iirrrl cornplesiunca lornbali se oxtinde spro coada cle cal, tulliurflile do rrrolililrrlr,inftr'acii,un caractel flasc, cu fenortene de neuron rnotor pcriI r ' l r(,r. i rlc lrirllllizitl,i,.

liut prcsi,unile m,ed,llla,re s&ar ,te realizeaz5, paralizii fd,r',i, sprnne pirarrrirlrrlr,, itr schimb cu nete fenomene raaliculare.Astfel, complesinnile la rrir r.lul opiconului (L,b-S?) se manifestd aaleseadoar printr'o paralizie llrscii in tcritoliul sciaticului popliteu interrr, iar compresiunile conului rrrlr I rrlirr' (S, - Su)se recunosc pdn a,bolireareflexolor anale, prin tulburdrile rlrr st'rrsibilitate perianale (in qea) qi pril marile tullurd,ri sfincteriene, :rbia rrrri lirzirL pul,ind si, apali, ma.nifestS'rileparaparetice. (lonpresiu,nile la nioelul cozii de cal realizeazS"paraplegie iloar in lrrzrrl sirrrllotttnluitotal al cozii i1e cal (r5,cl5,cini1e Lr-Su), insolite totdearrrrr,rlrr lulh uri,li de sensibilitate extinse r:e dermatomerele restectiTe si de rrrrrli r rrrr li l,rrlbu l,rrlhullli llli stincteriene.in schirnb, s]nclroarnele tle t1c compresiune comliesiune parnarprin l:tl-toUlan prln qi dc Oitt se CalaCleltzeaz:], ttlbur'dni m0lolrr motolii rotolii Sr si Senzltrl'l.e senzitir.e ln in rr (x,Zll cozii (le cirl SO caracterizeaz:'i senzitir.e {irr,li r llr,lir Irrrciic rlrr li1ul supe.rior(L.-Ln), mijlociu (Lu-Sr) sau inferior (Sr-Su) r|r' rrirriIr'orrr de corilil tle cal, intlr'unin.l $1telburdri , timul (cel inferior) intrr'unin.l rr.lctir.trc irnportante. rLlir I'rrtrxr'lt erpansiae intramed,ulare, indcosebi cer"r''icale (glioamo ,1rlrrrIiIrrrrrrrrrrr, i nbclculoame) reakzeafld,tablouri semiologice cu totul prrr'licrrlrr,rrr, r,rrrt i.rebuie cu grij5, diferenliate cle S.I-.,.A. sau de alte sil,lrrr:rrrrrr rlo S.1,.4., precurn 1i de siringomielie.Astfel, aceste:n se manift:stii r irr lr'lllrlrlcgii ploglesive cu semnepiramidale (mai exprimate 1amernblei.o 1r ou sllrsticitate), cu aljlofii musculale de 1,ip Aran-I)ucherrner, rrrli'r'iorrrrr lrr lrrrr, firr rlsociazili, tulburi,ri de sensibilitate suspendate (irritirrl) sau subIr,ziorrrlirrlo l;ip siringomielic, cu clisocialietermoalgezici. Pot s* lpa,rl plecum qi dureri de tip radicular la metrblt'le supoli. corrlorrirle, rli rlru'r,r'i ,rrrlr, lir rlr,rosc asociaai qi fenomeneyegeiati\.e (va,somotoriigi sudollrlc) rrrr1rolIrrtrItr. Irnnginca rnielografic[, descrisl inci, cle Sicard Si l{i],guc1rilu (lltJt!, cilrr,fido ll,iscr',1952),tlesemnindaspcctul in fus almldrvei dilattt,o, riu Hculllol'orr slrbslartlei radio-oplce po pi,rtilc laterale, snb fon:n:l lr rlorrii, rtrIrirrrc lirriir,rtrlirstrinlrto,vino sii confiune tliagrxrstictl tlr trrruoli, irri,r'it. rrr.tlr l:rIii. ttoscrr a) I irirtllom. i tl'i.a, rrslrrttlit,tiv lr;iot'tlc t'ccrr t,, ptin ilsocicrrlr, l:r,rrlr (srur lrrl,ltlrr,trrzil) pirrr,rrrirlrrJrl, irrso{,ilrlc lrrlnrlili Irrlrlorlrlrr l)r,r1rl)l,rt'zii t42

rl|. li;r sit'iltgrrttlir'lir', ,.lrrrsttlrlt'ziottitl rll' s(llrsilrilillrlr,,rrrrI|r,trrlltl,r,(irri(irrl) , ittltttlr' t t I i IIt tI I,r' , pt'r'tlrlttI t t I irrltsclr i,rrrlirttr, rrltt,i lttllrrrriti il lItot.t)I.(ft,0|(,si lrl1r,l,t , it,irtr,li.zr.i,il. itrl It'rt lrr rrivtilirltrriirril.r'qilr1rl.961r,l'r,lr lrtrr1t,r Nlrxlilicirlik,1,.(l.ll. sittl :tlttlc {iD ,\r'ur),1)ur,l('rrrrr'. tiilrr si I a1,r0liiLrr, rliscrtiit ltipcltrllttttttittozi)'l'rtltt';i' (cvelttttal itnp,rrt:rtrit' r.rrlr. i:ru luiirr ,.rist.r, siririgomi,.liiiu evoiufib rnili r1pirlli, .. 5l.crrj lidrirlirtrr qi t'tt ilttrtgirti i' tumor.ilc iltra,rcrlulirtr,, siittt{ii rl,, liniorlolin,,Lerrzi perime4ul*re't cr,r, -d ev gnosl il. di [il fu:rrl e ilc ia icul ,rrr.:rrtc d (boaln luiL'riodteichlitx'tlo tlrr't'itt i no-cerebektase sp treresccntek I Deqe -Marie) minime olorncult:ltirrtrli.tr corlrrporl;it, ,, r,L,iloasi a lui 2ie*e Int$' 'itrt' rrrirllle. ne Drim Dlan situindu-se sernnelccerebeloasc 1i tle col'(loilll(r i,.r'irart'.- lf nlusi caractelul ereclo-familial tra $eazd,tlia'grrosliortl' xt Paraiteqia spa'slicd' fatnili&Ld' a lui Btrr'iirnpell-Lorrairi', 1xr litrgri' glrtrLiologitr rrila,iiegia li"ait iAaia cu contl'actur5r asociazd,in contextul (uneori discrete),pe ling5,un caracter eredo-tilrttilirt'l' .i semnEcefubeloase itt hl Arahnoiditele sqiinale compresiae (diJuze sau local.e.);i -art'lmo'n titele iealizeazd,4e obidei paraptegii (sau tetraplegii) insolite rle lttrr'tttt,tttr tardivi f tle semne intinse, etajate ryi atlosca,tlistrttl {ltrrcroase cu apari.tie ' atingeri radiculare tlezordontrl'c, itllnrt'lt'"lii neregulate, rll,nte (hipoest"ezii ale Ir.C.R,. (in funclie de efectuarea punciiilor etajat., .tl.5ltt iruronsta,ntie cu lentoaxe de intoarcere la presiullerl'iltilirrliit 0rr,i ncrequlat $au Dar-t-ial, pozilie aqezati decit in pozilie culcati' srtl illv{rr$)' in l'l"cljul"fiintl mai iet j\lir.loeratia (.ste caracleijslic, (Arseni $i colab. t9?3)' cute Fi aronice t:ascwlarepot realiza palilpirt(^'r'- rlrr|| i) Mielopatii.le subct rrrrlallegii le-nt-lrogresive, al cdror iliagnostic este extrem tlo tlifitril 1i' pttiitttltt altor cauzerdiagnosticul lor prtNris face plrin"eliminarea ,,,1r.,si,r,.-se t crlrrlrrr! qtie ischemiilr Se cd selective. arteriografii so stnbili cloarlrin vrtrt tt. pot fi realizate prin leziuni Yasculareprimare gi prin compLt'sit.ttti ]rrrt in cadrul inor afec.tiuni ale m[duvei $i ale rneningdor ((irrrrritt r,ti 1972; Lazorthes, 1972)' Atotrt- ryirur'l'tt Iirxr(lot, L966, citali cle I-,azor"thes, r iosclo.ozavaielor lpinale este mult mai rar5, decit arterioscl:tttzit v:trr'1tr' ct'r'cblule (Jellinger, 196? ; Lazorthes, 1972). (BLA) este u$ol'lle rtlcttnoscttl' 1tt'itr i) Selerosatlateramafi,iotro.7icd' ,r.zr]nt'zl atrotiilor musculare tipice, indeosebi dista,le la mern5lrrlc sttlt.t i i,'rrt (cu sindrom Aran-Duchenne), cu fasciculalii )'li c-usomk) pitrltttirlrtlrr lrr iorite membrele (mai exprimate totuqi la membrelo infolioa't'c). tlrr lirrt'tlrr pol, li lea'iiztt'1t: lateraliiam'iolroficd de scleroBd' k) B inal.rcamele pa,chirlr('rrirr!{ilt' naturi, tle tliverse cer"vica,le rrrrrlt,e compresiuni irlectiuni: .r'r'r'vic: c liipertroficd luetice, arahnoidite., encefalomielil,c fortno .irrrlrr', v.t lt'lrt" iterjce"). LllrunliLListrlo spinale (a:a-zisc 'r'r'rl'rrrinlni colrb., 1973; l)ragilncsctt{i r{'lrrlt.,ll}li:i, i rr,., I rr|.. I.,. inr.lr()q.r. (Arscni !i ',cen1r'opt'l r1xi3, t 965). l\ Stndroatne'p&roplegi( ;i lelrupleglte ltol sii aprlrii' ill Itlllnttlttrlxo sttIr.rtltil'' ll' urol;lllui In,itut'lrclifcric.{'arovul li rrLrurrllrIr'itt .rli,,,tirrrri;r lr' rl" ill tlitLir', ltior, conlr,rlul .c dilt'tou{irrzri clle 1l;r't':r'Il|giil' lrrl rrrrrr:rtut .-i rrrIr.t,r':rrrlcuiileDilunithrle:groliotrti0lil,asnltilcLrl,iisa,usuborl)ni(iil,([i(1r politttrvl'ii'oltr lrniot,rotiil0rlpinilloplr)!{r'oi;ivrr, M'rr;i.,, i'hrllu,rtrrrrri,,tl.rjli,i-Lri (!,(lr,fi Il l ll,(11'iol .,\lnill l,o[,l ($i 1ll,(!1t('lilgltrrrtrlr,tii), llulir.ir'rliortlottovlil,trlu. ltttlttottlirrlr nttr,ttrttt la'rc {rlis1'r'ol'ii lttr' , it,,,, rrr.,ti,r'ii ., I 1i'rtir,lizrrlr' \i dt ltd,ilt tlrr tIiltgrtrtsli11lll, rtirl rtryot' rrt .t'ltlr, lri{r'trrol)rrrr plrrrsivr,, rrti0zilr,,p0lirrriozilr.),
I t r o o t t ( r , r i t t I i i t'ttti ttl tl |j i l ,'

l.l:i

i|.il.il. I'llrrlizii plirr lozirrrrirrlo rrrrrlorrrrltri nrolitl' prl ifori(1 ;i.;1.:!.1. si se'nioloqice Oorakt!;ii rttorfo-ttt tt,cliortrr,lt An lezilln' a lt(uron ul.rt i tttolorperileric. l) fic 5t,ie cil, indiferent de setliul lezi:lrlii, si,nd,romuld,eneui'on molor yrri.li'rit: irrrplicii o serie de caractere generale : a) deficit motol' proportio' rrrrlcrr rrni1,i,!,ilc motorii lezatc i b) hipotonie musculari' I c) retlexe osteol(,rrlirorlsc diminnate Bau abolite; d) contraclie idiomusculari pi,strata lrrrriila rrr gr:rd al atlofiei musculare; atrofie muscllard precoce li irupor' l:rrrl,ii,irr crrzurile in care este compromisi, integritatea neurollului motor; r,) plczorr{,r, fasciculaliilor (indeosebi in leziunile pericarionale) ; l) i'eacliile rlrr rlrgruorrscon!,ir, electrici,; g) modificlri EMG caracteristice de tip neuf0lfclt.

' l A l l l .l . l Ii gl .i ri l { r rrn' ml ,|1' l ol s tl p(.rl onro

N r. i l

t,
I

Il i di carca rrmi ml ui l l i di carea bratuhri

'1'raprz
"--* C, I3r* C..

Dintat mare
Ileltoid Itomboi d IL'tghiular Pectoral ,nic J)orsahrl mitre Subscapularrl

C" Co

Irri i rri r r iii (1(' i r, r \ | S pj nnl (c I.\ i |rl i (lilll:Ll i N c N ul { (l .rrl l r{ C i rc unrfl (\i N erv ul l 0l l rho hoi rl r l ri Nen'lll llDi.jhiLr ri Lrl N nrl li| N erv ul pe{ Lorl

Coborirea umi r hri

3) ]tr-'ris&l insii' o serie de particularitii,li ale distribuliei paraliziilort qi ale activit5lii electrice musculare, precum $i ale unor simrrlrrrrlrrrlliilor' lezionale: a) la ni ale toltograJiei. rrsrxria'te, ca'reprmit ili.ferenlieri. ;rlrrrrrrr vllrrl lrcrirrrrrionului motor I b) la uivelul ridS,cinilor anterioare I cr)la nivelrrl pl,rrrlLril tl) la irivelul nervului peliferic. lf) I'onlrr aprecieraatopografiei ieziuniior nsulonului nlot'or periferic rrrlc ut,ifii,olrnoaDtreapri.ncipalelor ac!'inni molot'ii segmcnlo,re ;i coretpon,ti, perifc,riaa (a. tabelele nr. I' II, III Si, t nla. i erl)etie' rad,iculo-med,ulare Iio. l[i, 19, 20,21t @up}" Iiiser, 1952 qi Chusid, 1970 - cu moalific5,rilo
rr olrn{rtlJ. TABEL NT. I lligeirile capdui

,1

Rotalia bratulili inaiDte $i inrpci Rotatia bratului in ahri -Cdrtuclia brafului

ca cn clcl ca

cs c" cs cu ot

Nervrtl rnxr(hri Ner.JulsuIs.:tll


N erv ul s l rpf)s i pi nos ul r I N erl ul s rl s pi tl ( CircuDrflc\ N eN ul dorsa al l rl r lru i r r r r ,, N etv rl l rotLrndul n d u l r r i r r f. \Iai Inul l i nc r\' ,ll t)r,,\,.rl l l c l i ]r pl c )' rrl i ) )rrl ri :rl

Supraspinos Subspinos Rotund rnic


Dorsollil mare l l otund mare Peotolaiul ma].e SLrbscapularnl D el l oi d Sup!aspinos

Cr cu 0r Cu
Cn- Ct

Abduclia bralului
fi

c, cu ca-cs cl-cs C,-Cu cs-ce C" Cu

CircumUex Ncrlrl sul scl


\Irrs c nl o' ( uti r rr I l l us c tl o rLrtr rrt l

Fl exi a 4nlebratrului

Biceps Brahiai anlerior Ltrng supjnator


Tl.iceps

ce -cr ce cr
c6-c?
Co C"

ExteDsia antebratului to
l '1e\i a nri i ri i

rygrl
Ii adi rl Mcdian

Pahrafii (mare qi rnic) Cubital arrLerior


Prinrul ;i al doilea radial extcrn Extensoflrl degetcl or C ubi f{ pos tc ri or

C t* C e

crbi!1l
Cu -' Ce co- 0u
i l adi al n adi:rl Itac l i al C ubi Lrl tr{cdiaIl ilubit:rl

Dlepli antcrioli Sternocleidornosloidieni


l, l \ l ( r s i l Iill)lrlIl

cr;.C, Per. XI. crao+ c , -c t


Cr-C" Ct-C'

Pr'nii ner\.i ar.nieni n. spinalI- ramura n ccrv;cali (lolr:l

tt

Ilxtensia r:liinii

,9L9,
o? 1)1 C' D' cr l)1

Splenius (lomplexul nrare Drcpti posteriori Micii oblici


S c alcn i 'I'rtlpcz S p le n iu s

q-c" cr-c,
C,- Co Pcr. XI -l-

l{xrele rlen' {rrcipilxl Marele n.n' occipital Primul ner'\'eervica]


Marelc rLcrv P dmi i 6 n{rri ccrvi rrl i S pi nal -l - Fl i mi i d,,i i r. f,r'\'i cali Mal cl c l rerv occi pi Ltrl

t:t

Fl 0xi a p oi i c el ui (pri ma f i a (loua falangd)

Scurt il cxor' Lung

ri t

I ||flillrrrcu l r l . { ' rr l l i

cr-c,
S l c rn o clcid o r r : r sto id ia lr slln g ( l r n r Ur lr xu l Dr I| r ( ) sllug S t ) l flr h r s ( l1 1 l) t Mnr'oh (lr'll. t x r r l l' ll( n r lr ' r I) t

l l cxi a i n dex tl ui Itl ter{ )l n,s ipal mx ri $i a mcdi us ul [i fi doIS.rli (D ri ma fal angA ) l rl cxi r { l tl angc l or Fl c x or c omun (s l |perl , fi pr0f.)

c?-, T)1

l l c di arr (tr1)i tj ]l

.!,!. t

1l

It0lolijr crtl)1rhri (sr'fc drr:rl,trt)

Per, XI -F

cr"-c" or--c,

SDinal l- C, l \l rrcl o nt'r! {.i Ii Lrl

cr , (:x or -- 0N

N trl rdrf rcrv rk ( i l Jl l rl M{rr!l o tr(.rv (x ( i pi tl l

i l (),i a d c gc tc l ol Ll Lc ros l ,ti p:tl rrrri 'l [i 5 fi dors r' l i (pri rnr ftl nnl i i ) (rL (l ouu tNl tl ' rl .{ i ) r,|l t,rrl r( i rl (r' Ir'i rl l r l r tV ri )

l -(? ' r)r i

j,',,,,
],',,,,

N { c (ti x rl ( l rrl rl l :rl

t44

l4ir

cqbcllI Corllnuarc
tl

(:o|l,llllalo trnbol

z
QnAdJicep$ul crulal L'n-l't

'/ liadial
Radial Cubital Cubital
Cubital Cubital Median Cubital Cubital Cubital Cubital + Median

I /

I lxl orBl[r l){ lccrlui llxlcrrsld lrlU rrrlo r 4 rl{:grd.c (primn hlu rgll) (r (loro $i a lrchr ftrlanEtr) A{l(lrr(Lin Fi |,Pr)rllla rhgcl.olor
llJ l tl

Lung fi scurt oxtensot Extcnsor comun Plopriu al indexului qi a1 auricularului Intcrosogi Lombuicali Interosofi Palmari Opozant Adduclorul policclui

o o -o ! Cu-C"
Ct Dt

iixtcn\iA Flexia pioiorqlui

c fl rrIl popl i l eu

I I '
10

L4-r"6 Gambier antelio? (Si rotalia ineuntlu) Peronier anterior Lu- st ($i rotatia ln afardl Extensor al Lu- S. degetelor (tn mod
Gemeni si solea! Gambier postedor (qi rotatia iniunttu) Ltng peronier latelal (9i rotatta in alard) Ganbier anterior Extensor propri[ al detului mare Iixtensor comun al degetelor J-ung peronier later4 Peronier anlerior Lungul flexor propriu Lornbricali ti interoso9i Lrngul fle)ror proprm Scurt llexor proplrlr Adductor propriu
I-ombricali qi interoso$i (pt. ultihele doid falange) Extensor propriu Pedios

'fibianul antcrior Sciatic poplitcu cxtcrD fll anrenol Sciatic popliteu inlerD Tibial posterior Sciatic poplitcr exLot.n

c"- Dr C"-Dt ce D.

Extensia piciorului

Ln- s, Ln* S" Lu- S'

dductia pollcelui

cr-Dr
cr- Dt cr- Dr
ce- Dt

Abdrctta (lcgctclor

Interosoti dorsali Abductotul degetului 5

Rotatia piciorului induntru piciorului in alar{

Lr*Lu.
Sciatic poplitcu cxLerD Ti}ial antealor L._ S. Ls- Sr Ls- Q La- Sr Ln- S. Ll- Sr Ln- St L"_ S. Lu- Sr n. plantar intern n.. plantar htorn Sciatic popllLcLr exlcrn Nervii planlui cx[(,nl tdrn Iibisl posterior Sciatic poplitcu intern Musculo-cutanat Iibial anterlor

2l

Alrductia pollcelui

Scuftul abduclor al policelui

I _.1 R o t a l i a ,

TABEL NT. IIL MlgeiTile membroloi lqlodoare

liJ

Irlexia halrlcehi Prima lalangd - Celelalte falange

Tibial posterior

vl

(l(llrclln A l, (luc llu


c o l l p Hcl

Adductorii Fesierul mic ii mijlociu Abductori Fesiexi miilocii Obturator Pdtlatul crural Croitor Psoas iliac Marele fesier Drept iltern Ilicep$ cluxal Somlte$dlrros somllllenrbrtnos Poplltcu 0rollor

L"- Ln

:urator, musculo-cutanat interll, Bciatic mare. fesier superior fesier superio! fesier superior Obtumtox Obturator Nervul musculo-cutandt extern NerYul crural + ramuri colaterale ale Plexului lamba! scia!ici

IJ

Extensia halrcelui

Lo-L
L, - S Ln- St
L^_L. L s- L 4 Lo-L"

totofla IitlrnLru a (roIptcr llo[n (f r th { (flrll lr 'In


c o[ pid l, f lorlll (li)rpsci (!n$ln

t5

Fl exia celorlalte degete - Pdma falange - A doua falange

Lr-Ln

Loinbricalt $i intr06oqi Flexor comun Scurt flexor plahtar Flexot comun Extensor comun Pedios (ln afala degetulul 5) I"omhlcall ti lnterosoil (pcntr ul[hnd( doul fslun{c)

plant{r inlorn il Ln- Sr Ll- St Planl inlcln plantar int(r:t plant0r lntcfn Dlautmilntqr:1 ll cxl0ID

Lr* fr
Lo-'- Sr

'jxl

0xlu g0r bol

L^-Lo Lo- Sn I-o- sr I'o- Sr

t0
sciatic mare Sciatic mqre Sclatlc male Sclallc poplibou intd Muiculo-cutaDot cltorn

llxtensia celorlnlte dcgcte

Lr- sr Lr- L*

r40

t4r

-Ttiaeps corPr - Exlensor rodidlis lonqus


B{qrhlcte diaI is ,flexar,'.carpi ra0talts ,Pqlflchs lcnilus

pallitis. Apponens pallicis Abdua.f.or brevts flexat pollicis Drevls ,Abduclor Po icis

sibiifiis Flexarccryi Abdrc.btdigili .flixor djgilj quintibretlts

coai Exlensor 'tudiolis brcvis 'fxlensorcffpi ulnoris Exiensot digikrun potliais Abductar lon1u5 Abdwlot Pollicis brcvts

superior(drept)' si membrLrlui F,t, 20. Muqchiisuperflciali

SFt

* ciis

&
.8

Atubusntdits noxinug Gluleus ailis Gto


Senilendinosus Eiceps fenoris Voslusblerolis inenhronosu,s Sen Percueus tonquS fibiql,is

2a

Exlensor digilorun longus

Anloiot

Fastetilr

Irl0. lr, Mur4hltrtrpol'llsldl al mdmltlulrrtInlopl0r (droDt)'

.i-,i.1!.)!. l'roltlrutr dr l.itr1tt,*lrtlrt1t,tt1rulir pritr li tliol.oqiritt ltrr.t,r.l,i:iilr I, irttti rr.lt|tI t|t|)|1.t||tt,i tttrlrtt1ntilr trl l\ l., itttil" p rirrtt'iunulr : l) I'olirnn.irlilr a,nlui.ourd, (lM,l,(, l,ut IIein,c-llh:tliri). l)rliciltrl &u,u,l,(i, rroiol sc irrsiirLulzii bl'utal in decut'sdc citeva oro sau zilc, rle obicei dupii o iorrrliilirlrlili, (lo nrulte ori inso{,iti,cle fenornenedigesl,ive, I'espilatolii 1r,,r i.r rlr. rr,rrrrrrnrorringe&le), dar uncori Ei in plini, sfnS,tate (,,pam1iziilede I rI rrrrrrrr.rr, {i r' ). Sc lcalizeazd, tablouri I'ariallile, cu paralizii limitate, parccl:n(1, riur, rIirrLllotlir-Lfoalte oxtinse, tuteoli cu caractexeascendento(sinsht abolite in zonele 'lr,rrr l,rrt(ly). 'I'otdeaunareflexele osteo-tendinoase ll)il,r'rapi{l attlfii musculancDihipotonii remarcabile. 1r:rlrrIiiicrr, jbilitatt-,. l,ipslsc 1,rrl brrliililc de sens ')) I'rtl irtm,itl,i.tn, plin deficite motorii o,nteri,oud, cronicd se caracterizeazS, lrr rrllolii lnuscrrla,r'c (rle rnulte ori rii cr fascicldalii), cu instalare fi evolutie l{'rrl plrrgrrrgivi,, orr loc ,lizare bilaterali, !i simetricd sau cvasisimetric[. l\l:rjr)r'ii lrljol,lrcos1iol ,r sint degeneraLive(rareori cu caractero erdo-familiale), c,rk, rrrri rrnrltc iiinrl dc fapt forme atipice de S.L.A. (Ratlu, 1978; Trillet rli |olrrlr., I070), iar unele cazuri putind reprezenta forne subacut-croDice rlrr prrlirruriolile qi colab., 1962) sau sechelelounei vilotiice (Drd,gi,nescu a,nterioat'e acute (Ileine-Modirr), in care atrofiile musculale 1roIiorrrir,IiIu rrrrlrlir.iirlc rlotolii, dupi mai muui ani de la stinger.ea procesului acu[, rtrlcp ;li, so extirrclil {i si se accentucze ptogresiv. Drpi, Radu (1978) {l \ rirlrlrrlrr, cir,ontil itli distincte a atrofiei nusculare progresiyo Aran-Duchetrrrr., r.rr,rlc lal)ir fi {l pa,raliziej bulbare proglesive Duchenne este indoielr r(ir,, rt'l,i.ii1oil leplezentind mai probabil forme atipice ale altor afecliuni rr'lr,rrrrrIr'orrrrIrli lnoitor (S.Ir.A., sindroame r1e S.L,.A. el,c.). Crdem, deci, r':r lrrlnurLrrlrlc ,,lrolionrieliLiilanter.ioar.i, cronici], devine incorect in etapa, :rIlrrr,lii rr,orrrLo;Lin{elo| noastre, pentt.u cazut'ilec1l otio)ogieneprecizati" Iritrrl lrlrlirlir,bil si $e nlilizeze telmenii dc ,,sindron tle S.L.A. atipictt rrr,rrrlrr ,,sirullo])r I )(r'icalion:t l anterior oronic de etiologie nepleciza;bii,'r. 'l'ilrrrl lrl rilr,i IrccvorLtintilnit este siuchomul amiott.oficAran-Dlchenne, rrr crr,r'r, rloiir,ilrrl rroi,or qi atrofia rnuscular5, incepe la triye.lul rniinilor, rr.:rlizrrrrl, oi)ritentolor tenari, |i hipotenarii [i :r, interosoIr'irr rr,i,r'olil, ,rl,,r',,,rrririt, sirrrirr,tiii') atrofiei ;i ,,rrrila in ghear5", dupi cale progresiunea l:r rrrrclrrl rr,rLi oll|ir,l,t1or, tg lrzaa,z\,,m ta t1elredicator.,, $i ,,mina Si antolrrrr,l rrl rrr'Irrrlrrl,icJ'. -,\tl'{rfia ss poate exti de qi Ia nivelul nusculatur ii bra,I rrlrri |i r'lriitI lrl rIl so[]inturalizomelici a memltrelor Supelioare. ii:ur (lrF(,r'ir.i rji cazut'i de ,,poliomlelitrd cronich" in ctre atrolia debu1,.rrz,: lrr nilrrlrrl utl$ct atut'ii proximaie armembrelor superioare,realizind :r,r lc prorrrlolrriopa,tice (Yulpian). tr'ormole de ,,poliomielitl donicS', 1,i., r r rlr.lrrrt, lir rrrcrrrlrlele itlforjoat'e (pe glupele tnuscxlare peroniene) sint
l l l r ll l t r r'.

'l .l nirlrol'i il.t: s1ti.tt.u.le progresior (aniotro{ia progresivi, in{a,ntilii, \\r'rrlrrr;1llollrrulrur, arr)io{irofiaspinalti jnvenilii, pseudomiopaticS, Wohllrrll, li rrgirllrolg-Welanrier) pot fi recunoscute[i diagnosiricateprin car.:rc| ,'r'r rI lrrl lorr ol ic olc(lo-1atrilial, prin masivitatea sjibilater.alita,taatrofiilor It IrIrL r|||IrIr'(|, irrirrl(,il,c a motonuro;i de al1,csernne de afecijare degenera,ti\.:'i rrilol rpirrrli : rr,r'olltrxil, modifioXtilc ll.M.G. de tip lteur.oosi.cotondinoasri, rrrir,Io1rrrIir., lipst s trrrrntrlot 11r.rr trir'lnridalo [i a,lulbnririlor d sensibililaitc, grllr.rrrrr 'ij (.llNdl, l9?8, t971}). 1i l)t'il o\'olll{il l(n,l}1n1,ictrli ,i) IJrrylu. (ttjr,it,iro.li() J/o'iI srxirrzji, l .i (llttt,t'.n|. irr corrlorllrl f(.Ilrio loyJil rorrtll rll ltrzirrtrt lr,rr0rrlrIrri|rIt rrroI oli ;rr,r,iliIlirriirIjI llr rrivirlrrl |rt'r'it.lr, i0

1 ' ItttItrt rt' ioItI ii t lottit'it),r'iI i1iI'toltrtllr riottrt,l (tttt iitttrltotrt rlt' , , I )()| i(t III i{|I i I I'i ('ill'lllrll'f lt,ltt lirllllt i{rllltf. tltl tjot'tItIit'tttI prrt ilirtir,, lrrrrluttt ;i sottttttl l)osl(n itl sttll lit, \'il'sl{r.1,itl0l(', Ilr,rrriIilr,I, itl c0pilli,l tjr'urlo. rlr:LrttLc:t'zir l,ritl rl'i,tolii rlis[alclocalizi,to1:lrnomblclt inlerioare, cuplinzir([ ittl,ii ttttlst'tllrtltt|rt' 1rr'rrr la illccpul ou (lolioil lrr()lt)r lrrr rrior'[, apoi pe cea gambier'; post,erioarr",!, plc:r,irnporta,rlt, menlinind mu1t5,vreme sta,liunca fi rnol'sul (c,,trr ilttrii rlrr lrr jlrcep[t poate lua un aspect stepat). Apoir 1en1j ]l iil rrr -progrosivr ll,Ilriolr'( Iolllizirr(l o\tinde in mod simetric qi la treimea inferioarii a co[],J)s()lor' frl,rofia caracteri,sticd, ,,in picior ale coco,i' (sau ,,in cizmii iltaJl,il,") li tulbut'iit i rlo tttoli lrozi{ie de mrus-equir a picioarelor, cu consecutiYle lilnte, insolile li do tulblrrd,ri ile sensibilitate ectromelice (strbi()(liivofii obiectivo). Xlernbrele superioare si]]t afectate mai tirziu, do l'egtllii ilri(,ilrl {n atlofie tle tip Aran-Duchenne, extinsi, ulterior pini in lr'eimca ttti.ilotrirt ?r antebratelor (atrofie ,,tn rnan$eie"). Existi qi form de tl'ecclo irrlr'(r boala Chaicot-Marie $i eredo-ataxia cerebeloas;, (boa1a lui Fritxh'tr irrlt), situatii in caro se asociazd si tulburiri de sensibilitate profundX, cu irl,l \jl' {prin"leziur ea fibrelor radicuiare lungi din coraloaneleposterioare) li, ov(rlr' t,ual cifo-scolioz5,,picior scobit cu dgete in ciocan, precum !i mioi fi lirr dive semne cerebeloaso. 4) Itt siringr.tmiel'ia se constat5, lrecvent semne motorii poricariorl:rl(t, cu sindrom Aran-l)uchenne. Amiotrofia, cel mai adesea simet'ricii, int{no' {ea,zd, membrolo suporioare cu fasciculalii' excoptional de rar apil,r'irrrl lrr, lrlembrele inferioare. Prezenta tulburd,rilor de sensibilitato di$o(lirLt(1 :iirigomielic, suspondate, a imporbantolor tulburbri trofice, a sindrolrrlrllri (li:rglxtH }iramirlal asociat, procum $i Yolulia foarte lentd, ne sugereazri liicul. 5\ Iurnori,le intramed'ulare ti traumutismele aortebro-mcdulu,rtt(:tr' pot genera siDdroame motorii pericarionaler asociirl,c(1ll rt,ll(\ hnnal,omi,eli,e) $ernne comisurale, indeosebi cu tulbur5,ri de sensibilitato de tilt si|ittgrt rnielic, de obicei inil,ial suspondaterapoi sublezionale(cu niYol (l{,5(!rr$i bilitate). ll\ Leziunila rdd,ic'LLlare .mteriodre prezintr, o serie de particllllll if i,li. I a deficitului motor $i a celol'Lrlirosorrrrri I)istribulia topografici' segmentarS, colelate a1esindr'omuhi do neuron motor periteric este identici' ctt |trit' tlitt Icziunile perica,riorului, dar fasciculaliile musculare sini exceplirtLrtl rlrr fur intilnite. Pe de alti, pafte, vocinltatsa ridS,cinilor posterioare facilil,oltzil' rlso riorea frecventi tL unui silfdron do protoneuron de tip radicnl'l't,' 1) Comprosiunile raaliculare (tumori, arahnoidile, hornii (lisrlrrl{r li s(xlllrr rli,o &fectimi vertebrale compresive, tumori vertebrale primitiYo s2l,tl rfirrt, boala lui Fott .s.a.) teallzetuz[' cele mai Yaliate sindroamotolx)gtrrli(1r (rorvicale, dorsale, lombare, sacrate) mai mult sau mai pulin o\l,irrsr!. llrrrliticilrils de reflexe (osteotendi:roasor cutanater a,rticull,re'pilolrrol(,lii, rrvsntual m[coase) $i aprecirea tulbu.rAriior de sensibilitate i],so(,iirl,(t l,r\ rlclrnatomerele respectivo tranqea,zl localizarea $i extonsia, loziunil(]I'. 2) RadicxLli,tela(respect'ia ma'rlingo-rdd'i,culi,re1c ) virc1,ieo' ltotitrtt sttlr $rr'rl rlo llto ctiologii pot fi unilalrorlllo (n&i mult sritt ]nfti l)ulin oKliins(r) l)ilr,l,(n il,lo. Jl) I'olirtdia.tl.on,(,,1n tltlcgitltr (trtiti tiw tlorrt ild( lt\tl t'ollizl irttblortrii;r{,t
( ]l l i to l l l l l {l 1 r l r , r 'l l p l 0 g i c o ) , |) o l 'i ci l ,o l o r r l o l ( t i i i t,JIl ,t'i tt l l tttl ,cr i 'ttl l tl l o l ' l l Il ) 1 1 ) l tl i ( o tt tl sl r o ttl ,o tl tl i tl ti t,si i , tl tt l ti ;tr t l t,ttr l l tr xi o . . l : r , r '1 r l 9 t L {! l tt( ,l r r r i l l o t' ;r r r ti l i r r i t 1 1 i Ir r i r ,lt0 l i i ) t1 i ( l o [t1 ) 1 o l tr \l l tl ttt sttttzi l ,i t' r r tt l o u i r ! i {i l , l t l r , i,o tr i r r tr tl tsf[|tti i

ll, l

rllrl lilrt(ir! :rl,il,piriLntirllt,lii, r'il, 11i lrrI,r.orrrrrIirrii,. X'la i rlifioii po:r,kl li rrIroor.i rlirtrlrosl,ir:rrl itr silrrrr,!,iilrr rIr,Ij|iir.|,1rrll')r'ii irr r.rrlrr lll r,iuli.cil lltr.rlrrt)rinil, trrr,trrIr lrrIoI, trtt llrlrlorr tlilic I)s(ilt(l{)ntio}{,iti(r..l)tbu1,trl bnrsc lrtrrrlrrcirtil yirsiN, do .r,pl,r'ili{) rrrrr Ir,Ir,l,iylnrrs(1, (l|, or.ioevlrstS,), a,l)olirea]rtlct{ol(r' ,rlrrrrkrrrrlirultso (rlroli cn pistrrr,rear.ellexeloridiomusculare),lipsa atr:oliilrrr rrrrrsrrrrlu,r'o in si,adiulde debut si mai ales n.otlificXrile lichidienc, cet rrrr.i rrrlosoil(xr disociatie albumino-citologicX, vin sE,para,fezecliagnosticul rIrr 1 roI i lr rrI icrrlone.vriti. Gtrillain,Baud. I) ilind,roamele coai,i d,eaal rbaltzeazi, tablouri multiradicuJare par"lilrrlrrrrr, rr,rlcsc:l, cu paraplegle,4A$cd,,hilg-tp[6r ?ISflexiE[ $L s11 at{oJii-rnrsortkllo. 'l'rrlburzirile de sensibiljta.tg pella4aler. in ga.Si tqlb.gr'rilc sfinetelr,ro irnlx)rtitnte ttimiln diagnosticut Oe potiomiitith; tifrsa tulbur{rilor. ,l(. ,.rrlil)ilira.h. ucllorrrelicd Gubiectivc $i obicctive)elirnfiai'dl;gnbiliaril rlr. llzirrrrr. rnctlula:ii. Jt)'isl,i\trei til)uri de shdroa,rne cu coadr,de cal : n,1\8intlrom.utV6ffi.\ol aoai,i. ite cal realiwnzd, oteritabild; p,ar-aplegie,pet! Irrli*i,, 1ltr,scd,, arafloxigd,r.i1lierosird ioate $rrlelo rnusctlale.alo rnembrelorrr|rriolr'o (cu integritatea psoasului iliac) 5icu masjve tulburdri sfino_
I'rrt'jtuul.

l i i r t l t 1 i l r r r t t t ii r l i stl l l r

lt) N[rulrontr isutrter'ior\ql, cozi,i,Lle ca,l.

prrlriir,l sint abolite ixl cqle achilicne qi medio-plantare sint pishate. rt xindronuL ffirior'(sauat 1 ol razii dr aul (Io - J",). Inlegrilatea rrrrr;r'hilrira,ntriori ai coapsei collrastcazi ru imlortaiita -.pariUzie-a rrr:r.iclor rrrusculare po$teti0-4re, inclusiv a mugchilor fesieli ,;i gambieri. l'iciolul cstc balant, ou tieticit de flexie-extensie, intilnim nD impo*ant rlolicil, rlu flcxie a garnLreiqi mari tulburd,ri de se)rsibilitate perianale, 1rrlrrrrrrsi pe fala posterioard gi externS,a coapsei gi a gambei. Reflexul r')l rlilr fi rnedio-pubian sint p5,sirate, in schimb roflexele achilieno qi rrrrrrlio.planta,ro sint abolite, lt]ulbgrlrile sllgleriene r i,irin pe primul plan. li,.fllrcL. rrrrrlc (cxlern $i interrl-sint aboliie. Pot .'i apalri si es'care. I'r'olrr.k, rlo elongalie pentru sciatic pot si, fie pozitivc. Teoretic ai.Ti nlilttt irtrc leBiunilecorrului Fi ale ep,iconului meduldr.fald 1r,' rlril:r r/i/i,r'r ,lr tt ittuilr,,'^-iIL]e rtrl.Inc[ Lhermitte (1919,citat de Riser, 1952)precizase rrrr,lr,rrlil,rrlii rlo tliagrnstic diferenlial: in leziunile conului qi epiconului ,l rlllilr s'irrl n)li ])ulin vii gi mai pu-tin persistentein membrele inferioare, r \ r,nr iiorrnll lrri Babinski, asistd,m la o simetrie a tulbur'[rilor cle scnsibilrlrrirr;i rle rtotilitate, la mari tulburlri sfincteriene si genito-ur.inare, rrrrrfi lrr o paralizie atroficl importantS, si a, muqc]rilor anieriori ai I'r','r Sc irrrprrrnc;i tl,iagnosti,cu,l tliferenlial fa\d, de afec!,iunileprostatice, in rrllrrlcrr, lrolrravii simlind pasajul urinii prin canalul uretral, precum qi l:tlti, rlc, ltti.tr,tti ontinpe al,epleuului, lonzbo-sawat (ca de pilcli, in invaziile Irrrrrolrrlir rrlc micului bazin), care pot simula un sinalromde coatlS, de cal. lrr frr[a unui sindrom ele coadd, de cal se rialic5,foarte malte probleme rlt rl.it rttt.o;sl,ic tl,iologic : ne gindim in t,) .Ln,cltzttl rlnei, i.nstald,ri rapid,e, aaute sau subaautre, joa,sii(lombarir,), la o rneningorrdiculil,i,infoclrlirrrrrlrlrrrl ln o borlll I?o1;1; (iorr,sii rr,r'ozii rlo cill, ll, o prr'i,lrtr6iro vorl,clllllii pliu tunrot'il 1r'irnilir.ii rarr rrr,r,nrrrlrrtii, rr,rrolo;ttt0i vtu't,olrt'ttlo lotnltit,tr'. lrt rr litttlirut'lttrrrlotrt;ri,ozi'i ;rcrrli. t5:l

tl;tt i1irrtt soi ,hr,lgiilu brrsottlii,, r,itrtl irtr boltrr,v rr,rrouzrr,L lrit0vit sri,lltit,tnini r', itt rlIrt'icrt slitt t-ltt ittllrttliili illrrliari l,osliaulrIr'o i]i 1xrrinoi[lo, ]rooulrl Ii i ttt iili ltt tl0 srrtrl tlrolrlenl,ul ilt cirr.e au sui'vcnit Ei lorlo ]onololilteliotr ;i l,tLlb lotttlttr rlirigrtosticul tlo in inbi],ndorti'lm lrili[a1,c ;a, trebuie categoric sii scilticri ban:rH,,,siilii xe gindirn la o compresiuno in cozii (10 (,i ' rrogittrlittt lan't-progrtsiuo sau cron.ica b) In cattr,L rtrvi euolulii suba,oute irr prirrtul rind la o campresiuna a cozii de cal, in spocialprin tutrroli srtlxltt l e primitive (neurinoame indeosebi; limfosarcoame ;.rr.) sittt ttlol,rr'" IIotl' si:ltice (subdurale sau extradutale), alte tumori extrrldttlrrlc,borula, elcirr, alahnoidite chistice pseudotumorale, sau la comptositttti rlrr rrli'r'1, rrrinrir. inclusiv rertebrale (boala Pott, metastaze !s.tr.) lll) Lezi'unileplemLrale te^lizeaz\ silldroame de neutott tttrtlttt ;rt'r'i' li)r'ic cu topoglafie palticulari', uqor de recunoscutr pri]1 ertenBla, (x)lrl'rlr l,ului semiololic in teritoriul plexului respectiv (cervical, brahia,l, lortrh;rr, siloritt,).la caie in rnorl obliga-turiu se asociaz; tulburi,ri dc seusibilil;alrr iri ta'ofice in respectir[l teritoriu tle inervalie plexurali. sanxiologicd' Arnintim pe icuri colt.stela,ti0, 9'i problem'ele{k dr(llttorlio r:liologic Ln sindladmela pleaulare : 1.) Sind,rotnul d'eplen cemiu'l impiici : alteratea mi$clrilor tic IL'xirr, roirrlie qi inclinalie lateral5 a capului qi a gitului' la cate sc pol, asttt:i:r' i,ulburi,r:i reSpiratorii prin paralizia diafragrnului, prtcum $i trtll.trrtrlri tlr', n'nsibilitato in teritoriile ratliculare Cs-Cn. E*te reahzat de multiple afecliutti I tr'aumatice (rlt colonnli tltvi malformrtive {r-r'zi Arseli ,si rrolllr., inalte), tumorale, inficlior-r,se, ra,Lr. ll)iiti. " "'1;1' g i nd.ronutdaltlel,iru.bdpoate fi reatizat lie tle leziuni t'rr,rlicrr t-mnehiuri]or l,r', 1i'u-[r,), lic,le'tr"z.iuni-ale ltrim1 re (sllln'lioI',trti.jlrxtrt t -(suporiorrirrf(rri(rr .;r i,Ui..r:iur), Iie rlr' leziuiri rte trinchillitor sccundul ptexului insuqi.Ca ataie, se pot rlistitrgepatnt, I)trrittttlt' q,iptxt|r'ior), fie '.rle

cl tr tt l r o l ' I o i tl i zl t, ttl t si tttl tr tttt tl r r t o :r l l i tl o r ,l r l ' l ) o p i kl l tt

'' "''".i]{rifl,i,o,rutde.mialiiri-tiitiio pterutr+i braltialst cirruct.rrz{trLl


intreg membml superior rb$lxr(rl,iv, lrlirrtr-n paralizie c-o4qd9-t[;-exf6d"-ta |rr anestezie gtroba}i iL teril'oriul intregului plex' sipelioi,rte plea btakial ( By'.9fu94.?q-Hrb b\ sintlr<.nnul ), itr citlrr ltrzitt rirliicinile Cr-Q, respectiv teritoriul nervilor l-nruo$lrl rLr.:r intereseazd, plirl ilt\lil'rl ,,ltir.lr&l li al riicllcinii erpe.gle! med!4nulyi.se rrracterizcazr'i blahial lnleliordtutg rtt;rrtrir ilorllelt oid,/bicrpsr/ llrrruL.i atrofin r tnrrr,.b lor';i nui pulin a muqchilor dorsal mare, pectora tnarc, diltflrl tttrt'tl iii rr,1,nir(l maie. Rellexele bicipital gi stiloretli4l sint rrbolite. Tulbltli-rIil', tlt' (.,rrcsprtozilL{)atr'((r.-("!). p|ezcntr'-[r'derma-ioFier?tr' ",.rrsibilitate "inf r'1 sindrcmrt injer.ior, da plex broh;Ltl ( 4t,lrupLv'lM#t;rldJ, itt crrtr' Co-D,, respcctiv lelilrr|iul trctVilot,li:ubilrtl .,.ziuncrL inlerclcazr.i'.,'lAciniIe il-lloJgliiltlut.fuulrrrr pliu rlr'lii, parli:r,l sc t act-erizeazrl ca r alsncrliauutui, li rniinii ti ri gruputui intern el antobrat/ului' tulbutriri rlo srrtrsibili "Lilol (itt (Cr-D1), llt, trlltc sc itstxriltzri lrrlir pt tL:rrniilttrneroli cot'cspurrzir,toa,rc rttL sintlt'om Ol:urtlc Berna,rrl-IIotnct, iitt tr'lllrrtl lczirrrloariuliorr[urii') tsl,o rr,lxrl.it. l:rrlriCo-prrrntlt;ot' rrl itr {':rtr' l{ /ritrtrr'.r rl\ ,^-intlronrtl ttri.jl,riu ir 1'lt.t:htthi'rl .( Hc.mt,tlcl l,.11.s(;rrii uitlrilitr:t O' tr'.plr'liv t''l il',litll('il(lrrlrlll"\llllli;i rtlfruli:rlrtlrrr. tttrttot'1ilt'ltirliutt, lrrtt4rrltilllt/tl'itropx,r'i'xtr,rr ir.,'r!r':ri,lrlizt.irz:', Pliri rlr,licil,

i
I i

t 0il

I t i || t{ r.

l,f. ill',fl.llll,,li ,(ureori |,,rrrl)rr'sl|rlrL,l|f , r , rrl )rl sl |l l l|t il,\rla, il\ lt a. ca p tl d A ia p u rl d to ri i de nl (} rvent,i i chimr,c a d e pil.ld, l a purthtorii Ii c. j d e (,i cirje, intewenfii chi nri , _de Icgluurdo mai SUS; l:r,.r(,,1)r.:rr'r't,''ts-l traumalismeobstclricaje,cu L.zirrne:r rImpllt xnui bazin sirimt, rrnei .nrllerii (consecutive !f::),'],1'.'.,,'::nlrr,rn l)r'r'?r'hrirlrrrtel{'ctuo-irNc, unei eompresiuniexercitate tle manevrele obiitetri_ , :rrr.,l)r'lr,\l l ptcxului intre claviculd,Diprima coast5,elongafiei sau smul_ llr rii I'julir.irrilor') elc. I,'\'.yil,t sa.* r(:Iiculitr ftslp?t;, rudiaut,,pntii)t'intec!i()1sr...."4oxi.c ,b\. r.t:tprr,(., ,( purl\ ac.tntln. l,r':rsr.t1r1 Su.feriu,!e tlc ditsersenaturi : hpondilite (indeosebi morbul . , -uertebrale ,tumori Yertebr.ale, r.rr 1) r.(rr r.('r'vrcar) ; i.tr_ara,hidiene ;i extrarahidiene; lrrrr.lrrli;i rlisiocllii vertelrr'ah.;/herrrii de tlisc cervicule. _ coslt)nertpbrolc deJileu.tu i sralar ir rr6oastri cen.icalii, ...,'.rt .l':'rr!!:i .alc :.||Inrrr|lr{, Ni.rtcnlce, rcalizalo ^si indeosebiprin tribcnrofja nru^chirrlrri scrj rr.r :r.rrl('llot, crre lxgrslcaz{ ,.defiieul scalenic',(saptiul rliltre cei doi pnnra coa-slii) rqicare iD acesl mod r.omprimi,ple.rul br.;r_ if l,li,sr ll' irr'1(,llt il,,l :',, Ei rrrr suDctaviculard, (Arseni qi Oprescu,196?; Ionescu,* popovicin rri culalr.. .1.921 ; Riser, 19b2). ,.1 rl'lrmori ale, virtulyi p.1r$g-n?T. Sinilromul paneoast_Tobias, in i . cru,. Insii p,aralizia plexuliri biafiial, inti]ninr dureri qi un siDaliorn ,lr.
lJIt t}:l ro_ liorn er .

l';rLa,liz,irr do lrhrx llrlrLiill r.nla. rlc tliatrtrr:,tlit,!,inni: 2r.r,r/usri , tl 'laniu,ni l,r& ryjeliq?Irr,rrivr.lil colorrngi/cerricrr,t,, inierioartr , li,diorr{ir,l(, Nl lxrljr)rrre, sa,u la nivclufclu,viculei, a/riL,xilei si l-[ zonelor sujpia_ si (.tuIi,a irulrllrrr.ilrrllrr; ,1 frlcturi tertr ale claviculei, viculei, ldxaiii scapu scapulo_humerale. lu.h umcl1l lc. cl,irrga clotrEai.ii rii 1,,,.1,,:]i l,l,l'..],,; lrir .luxa.l.ii

r0r'ror rui1 rr r'ir,iDitill .. rrI uu,uri ri ryi ''i,1";;;lil;l,; 'l ,;r,,litt'r, ili',,'li,lliiil:,jil

Sl qlf plerului

ctriar..r.u snrulsprea I'iitticinitorl;

. : ar . l: +( t tnt , lr t . . t l, sr ' llr t t lt lt , t ' llr it t t lolit r il, t t t olor , )) L' dr't . i. r it . t nr t r u, lt t , i. l( r'ospccliv (1lr I):lI('zl, rrl tnrrrychilor' lricops, lrrrr[rilrl iull,oriof osicot rtt,olrra,ltiit'I, Il ttxi ci l rrLelr r ir lului ( suplinit iL do hr ngul supillr r t or ') ; ; i r r ,r 'ir licli'r 'ii t t t t t it t t lt t i, irso{,itr"rde o hipol,rofic;i hipotonie a rluiiohilor lo.jii ir,nt lrt'rrl'tlltri. t',r'iorrrca, 1l'rrlburririle do strnsibilitate sint mici (vezi f ig. 22). h'uctori etiologici mai imporlanJi r pligi pl'hl at'mc albt, srttt tlo lixr I It ilcl,uli ale hurnerusului I anevrisme ale alteroi Axilttt'e I r:ottrptr'sittlti (1u'oi'csiorrale san in cursul somnului) ; nor.lile (fotrrtc rtlr).

Nervul circumflex
Muschiul dellaid Muschtul ratuhd mtc NervuI musculoaianat ,qomufl culanate

Muschiui biceps

br cnhial Circumflex Ramuri cu.onle ale antebralului

:l) I,'arlrliziile d,eple* lom,bar .(traumatiee, tumola,le, infecfioasc etc)rr'ri'rr'1r'rizi'|ilzil p.ir deficile motorii cu atrufii ale coapseigi prin dureii ,.rr iIIiIr'IL||Ir{.}n lct'iloliile nervilol,abdominogenilali,-fernurocut:r,nat,.i
, { t , l il {} {,t u t.Nl.

I'ut li,ritle_d.1 tt(lt sstat realizeand,rin context semiologic in care . ,ll Ir|||I r||it 1'll'uii rilc din parlea,ner"vuluiscialic, la ca-rcsec,sociazi tro_ I || ' .(. I tr tr.sr.n., rlrrrr.r'i pet.inelle si lulburdri sfjncteriene(plin afectare:isfinc. Ir'tllrri ltrutl rrxl;eln ). l.:, i,,: i , ur periJeriri pdt. fi izolate (nevrite, neuropatii), .. l:tl r)Irlt : ,, : ,t (mlllUnevi.ite) lterr iriroi.rrr., rltc sau extinse, bilatemle gi simetrice-(poli_ rrr,r lilr', lxrlirreulopatii ). | ) I\ruli:iile i:olnle flte nptrilor pcri.tpt.;(.i : l) I'uru,lizia ,ner.uuluicircumJler se traduct lrintr- n tleficit motor al rrrr..r'lrilrrirl|llrrirl,."cr, (,r,crccazd dificultalea,5i11r.,i.i.i p;oicc[ieiirrainle I rrr':rl r t! t{'s-l,r{.ttv.ir tnentineriiacestuia la urizonlt ji. Atl,otia mu)r,hiul i | | r.|||,.|| I r,r'r'r'rzi] rr|l_rrginea rle ,,umi,r in epoletr) sau de ,,umir tfiiat clesecur.tr,, !r ||r.| |.| | ||t ||:I o relilxue a articula-tiei scapulo_umerale.paralizia muqchiuIrrr l.l,r111rl rrrir,.,impietcazii ltri;oarea de rolalie ertem5 a bralului. liulbu_ I irrr.: I rtr' $('r rNil)ili1 Ltc sr.distrihuie intr-o ,,zonir, de r:lcheti,)' pe'fala rxternl, ir llf)rit lrln' (.l,iU, 22)u,ni tts ti,ntni.ti.. fractuli ;i rlislor::iri ale cu,pului ,......,1r.::.",,,,r: ,i,:.,'l,rt.t1iri 1r'urunrr1ir,, (pljn N,rmcnll)o $irn de for_) com])rcsifti lN, t'tirgr ; :lll,,,l l;,1, rr\'.r,r l'';'rrtr' (l)rr,li,si{nl'1,,, irt cut,snlsornntrlui, silrr ilr curlrul irrr.slr,_ ,||lrt ;.1|.||| Iir|| 1,. rrr.,rrr ollrlii 1(lrirlr ((l11 0xirl rlrr rlt|'lrort),r,rrrl0.t0xict, (tliir
lr' l l |r. l i r rl tIr' { .). ittlr.( tio itst,, { - lt . "r , t l) lr , t , lt Dt |r .

/rr.

.r. \"f\i i

c i i c url rU c \ \i

".' rs , u1oc r,l l l :rl ,

lrli rr cnbitalul :rnterior, lungul supinator qi fasciculele cubitale ale flox rtrtrlt I i i,ornrrrrplofund). Iilexia falangelor distale a,le{legetolor_?r[-4.{t'orli.ttt.ijkr r,irr r,sl.o imposibiki. ll\carea de opozilie u,policelrri trLt st.poal,c trlt,oltttt' Sl lealizclzl l Iiirrrl inlocdilS, prirrtr'-o rniScalc rG n[duZlli.ai fi,]iclri. <lttgcir',t rzi(it: in a,bduclio d, policohli po ltnlali llan r:u oolela'lto 1r, (fx I illllir (r,mlna, rtIt olit,t,ttttsolx)11(' r:rrlr'lt olie rl eririnon riitttia4ri"), qi prr rnrrs<rrr il: 'i a) . l, r r lr , xlt t lr lc it t r lt ir lt , t r ': t pt t t t t t'rrrrt rI r,I rt i r,{ rrI rr i ( , 1i11. llrl;rr
rrrrl ui (rr,ll rt i I 'illor r i 'l'r , sl, t t l,,,l: i. u. l! il l, ) polir , r . lr . 1i r lcgr 'lt t l r r t 'iliil, ot r lt t xr r

| fi[

ll.r'l.rrzii, irn {I(,gd,ulln i jlot,iLrs. i'lrrrl urrzii, doa,r, ptrr,f,inl, rorlizind ohiar rrrr :rH;rr.r'l,.tlrr. bucleil, (a tui Pitres qi ,I.estut) ,,gr.{ii.medianl,l'. J,:r,,,pr:oba, (.1i1.. c)r lllangeta irrdexului Du poxte si, se u,propie de cea a'policelui, .:!:i rrr;l li.l irrcll;trici nu poal,esL string5.1n obiect inlre ]olice si extremitatei, cr.lrrr'l:rllo rfrrgcte. l,a proba. ,,{g!!ilgr_-!_nsnrciqate,' (.fig. ZJ (t,), lTd,exal rir rrrrrlirrsrrl rlmin intinse ,,in sdg---e-at$1'. Un alt test eonsta in'iinposibili-

(n
m ei i i anul uj .

rtt l rrxi co (ti rtl ' , r t i izo|r lc lr nt vt 'lul t t t t r li: r t t t t lr r i; ; r l) l'zi- t t r r r ': r . t t t t 't lj: r t t t t lt t i r lit lir 'lt lot lot r t it r it rrl ir r t ablot t l * i " .i " " -ti f .fn r , ""Jcar Dia8cslccr r lclet ist it ir ,

rrli qi rl,rlr.rrrrrlio irrbu{it{' lnudj:r,D, ncr.rului io".o in t6i,iioriul *l*ii iuoe.e (sulrr::rtlrirrtrl:'l in terilotiultlislal .i,:l;"it;-;;i", ii .i dc atlolii muscularc
rt(' totali a nervului cubitl,l so(11rt : gllfA cu'biLrId" de minh icuhru ltrittt'r ,,in itr in exlensie,iar |eiilrltr' rlotti IrLlattgc Ialangi a degetelor se r1.g.lr' rlouri, ; atitudide fiind mai exprimatn h ultimele iiu"i"l-r""".ie jnicro$o'so ,.ritrl frl U"e"iJ mi" se menfine in --qbd,i;ie, iar slaLiile. primul spal iii inierosos (''a qqu"a't,+bachc'ii xllirt(r inift'ebi ,i""ri,i". *i.a,t- l"i S-i.rrd).'b" asnninneacrrrirent& hipofcnari cste i4rlrlizitiir I ii inforioarcrt :r'tl1r'ltrrrtttltri il. ot.ti'alc, iorso 1leniveluT!or:1iuil .i'io f " ';.iinii), 'd'.r,torit5, c.o1u1 prof.ntl ;i .ttlri "rir" fleror'lui cru!5,rii ;l;;;ii;J;i la o pozi{ie a nriinij cu ullimele d('ui ilogcl( rrl ,-nt".ioif ^liiltn intelosoiilor se compromil tnilciitilc rl'' ubrlrrr'lir' 'rf.lri Ji P;i" piralizia t[\;; ite degetclor; e) beficilul Ino-torinrcres"r'zi 1i tlcx irr' rtll i "i-0" ",Oi*i* aore i"g.ie, ddeosebi a degPtuluimic' precunL.)iudduc!irrp'rli" t"fot tlt' rtlt't par[ial aceasti tulburaruptitr miqc:lrt':t lui (bolnavulc6mpenseazd, l .t i' rr ctthiLrrl rrn muqchiulLri t) Paralizia medianl; nemrl riii". .*ilt.i;.p"iir [rr'rtrr.trl ltti ;;;i';;;,;;.[ un tlcficit rl adduc!iei!i d llexici rniiLrii igr Testul ailtluctoniiui policelui, in sensul,c5' bolna'vul tttt izlrtt ;;i;;ifi;t !;irtiria cu mina un ziar siu o hirt'ie intre policele intitrs .6i irttl.r i;-t";6;i;; a polictrhr i- rti rla face doar prin flectxlea ultimei fala'ng-e i;l';i;;i;;;; tlt: ,,r'ii* Test'ul median) prin ucrvul l-h';, i; policelui, rcalizeia ;rl;-;;;;ll pcstc it'lli) una aplicale l'r'rrr r-niinile sint cind atunci iir',r,"'i, deEetelofi e:trem6' de par,lli abduel.ic ti,tele lor pa*Imaro.qicu degetele_ _i.n P:";:':i iri{ir' intre tlegol'tr

o r)istanli rnult, mri micd' ,"ie .". .iia"tiirre ina14" "fi" cu fala lrLnara pe rnas[''.rrriti fiind a6ez-atd, trlina ii ,i" o"tLo *X"Xl.asXI iar txrl, t lr' m-j ciegeiglui

cu Ia1* ltrtl. f f ;cu mina.plasat'i iutmrrii"t" ri" Oegetului-midiint'ebOIitA (scrrr'rrl d.9gc-tul.l4jq cq poat'e zgiric"masa u'ul sd tru rrr.rsd, bo"6a ;;;;;; 'piir"rt ilSY*,f localiTate sint d! Tulburi,rlle. r.r iri se=qlbj-titaLQ ; 4" 'l:':'

Fig' i, ^ lr,l !1. ,,LL,r iL :lrrru,i)lj r Pa.alizjr !

23'i

x'i#A#il ii ;';t; Iti"*g*xil],*:'*g*r**gttl'*tm*'"'11"'#


vul'urlriltl'-t'ut'tt' m)-Tr-rlb-u i, i;,.;:;; se Xi a.'.^"; cu-caiacter i,,'r'qraat,er carrzalpic: m) Tulburirilo cauzalgic; riU,,eo,i asociazd Ii dur'cri "^."^-;""; in lelitoriul nerfulul (delonntlll irlr' ;rr,.rrorii si t rofice se intilncsc atlobea o*c,i"ioi."a pielii, cianozd, pielo lucioasS' qi subliatfi, txlt'tttr.' ;;";hiii";; ovdntual chiar ulceralii a,Iedegetulqi mic). : a) Leziuni IrcunaIl( la.nivclnl coi ttlrrr I'rincipotii faalori elinlogiri ale ncrvului l& nirelul itlrlcl'ril raI,;'plngi huninrusrtni 1-di r,,,,r,o""ttiri contlrtr' liziunea :lrLeleicubit'al'';1 rniiuii (adesea o.1io41'so-;i i,ii,,ti ir'li"i " (par'rliziir pisilolm osul "f Ie ina pc iiiiiii ,1" 1t'nutito. nervo:l,sc-tr'rm ',( '.{.sto,]:it'tciia1" rco:tstii' ti trot soalenic g;'dle d'eJileutui ntii ljlor"'l: b iU '?bm (,:rlli; lri])( 'Jlrofiarnuschjului snllcn an[eriol, cu ingu"l:rt'ea-,,deJilottltt-i pot ap,lclr irr/lrl(s,/lcltil'/li'lrri' r.rr,I r.rrii . i ) 1 ,'; r)aolile rultilale ittTec!ioase ri (livct'se a. tnalurie viroze, lii('i'lii 9. tlo strttttt" neruth,i tatl'ial se carrlcterizcaail' 1tt'inlr-rtsct'itr :,:,),1?araLizia ('rl,l'o tlt' s{! lr'l' itt l\1111,{itr lt:tiutti,i, rltr srrTi*l i' lirrC1io lrrrlrrgirirrrr,,ni.r,, : rlis{irrgo1;t,1tuva't'irtiil,i tnyttt xt in[ (purali:irr',,,ltnhirtlir" hldii u ttt"trttltri l\,))ln ptrrn,l.izi.rr rrltirt" ru)';\trir lr'rt{'ttl l9l:') Ilirt'r, drrxit'i itru ,r,tiilurd,r'tnhtil.t ,ur.tir," "

ilu,rll,il'ir ii";l;;,ll;fijlir,.il*:tf,',.:}"!!!iliiri'Jll'''::'ill.i5'Jll"L"'r;#:tl'Ll,i'ji1::l*ill; ,,,,, ,.,,.,,.,;"','i,ii.;,Jf;-J'.ii"ll tin.\, t.\t..!, r . r",,ri,i.,,,k 1"il :i.::.:',"jJ'"', ;:"J^fr,Ill"f..l;
" n r.I..|,.d ,-;g' dtA' r .j.' t) p' tr a:,?.\1r l) j?*t"ir o.r :_,an":Jl

rl I l ).r

lrrllrr llrxici rrltimci falange a rlegetului ariltitor', astfel ineit, atutci cind r'|rrir ,.rl(! rrrjozirlai. cu fala pa]marii pe masd,,boLnlr-ulgg pq_?!9_-lg-ZCil!g rr:rr,rrrjll urrghfu degetului aeitnlotl Unelo mis(.ii ri coEi.h, srtrcrur,j i{.,, .rlr, polir,r.lrri " celorlalte degete sint imposibile sa,uincoinplete 1i rr,le (indeo_ jlIiI(r rlo prehensiune qi t1eprindcre ir,obieclelor). Itriri( ri'.1)r Nir trebuie sri Iil,ir||r |ii rle rnulto ori apal dureri cauzalgice,r]rbotite t1s tulbur,:iri vaso_ rrrrrlolii ;i l rrrliicc,limitate ldhlvehil inAe.iiitui,.i aimerl jusului, in special
l| il rrrirl in-t ( lr. net - v UI lt i m er lial} .

I sc consl,ati dolr l)c ur.l i,-,ritoriu par{ial . 'l'u trut i}'i}:. tlp- S-eg51bili.tpl-c rrl z,rrrr'i rlr.itrllvrrlic lr,Iu'rrrrlrri mrtlir.r (.[i,t.:'.j ,^i. I'rin.ciptlii.lurhti ttidouit,i t a,\ lczilunilrautta.ltceh rrivolrrl br,:r[,ului , (Dlrtiir rttrtr,irllrrr rlrrlirr.,I,,t[l,l!rHilllri, slrrr L,ziurriprirr solu{,ii l)r'it) irr,jr,,rIIIrL| l,jrt;r\r,ni)r lrr rrirr.lrrl lrlilii lolrrlrrr); l') rrr,vlilr,itrl(,r,li,r.rA(,; r.i r)r,rii1p11,ii Ih0

1t,?

cutanat a! cubitql

Gheora cubitald

FlexoruL profund
'ol degetelor

(logcltrlor'"(a,lluilr'Iottlolll) rolol'(fxl'(,rIr.l1)lil()l'(logoi('lr)l ,,r'ilslil'iXl'ii i n)'I(rst,lll a-tltrgtrkrlrr, ll cfcctuarrrl tniqoil,riidc cxl,ensicqi indeplrtarc (r'iisl'iraro) rlc nrrter Dirralizati' nu sr: observi tcndoanelo olil,tlnsorilor' (Ji11 25 b); ,,1 destul ,,itringerii miinii (al lui tr'roment) de asemonea alatir, cL (l(r l)rrl cxlonrorilor, niri I)r'(tt'trrl li.a lc ralizi tir,nu se evid"nliazd nici tendoanele nent-a radialului extern #ig. 25 c) ; p) Testul prehensiunii uttot ttlritrt'll mici plasate pe un plan orizontal (a1 lui Pitres). Bolnavul nu pttitl'tr sir' a,pucdobiecte-,intrucit pe de o parte este imposibilS ridicalon, miinii si rr' (l(g''it'l(,r' {" nijmelor falange ale dcgetelor, pe dc altb parlc IIe-\iunoir" r'i rlrtlolit:, paraliziei llcxorilot, ilce ttificil si cu for(i rcrlusd,nu ilatoriti rnirtit sr,' pot decit dacii de flexie funclia exereita nu-qi ci, ace$tia irpl'ului :r,fii in cxtensie. In schiir.rb,flcxorii vor funcliona foarte bine tlaczi so t itlit'r'r rnina de ciltre examinator, sau daci, se plaseazi mina in ii,titutlittcir '.rlc po 1r'r'il'l se rer:narc5, lusirciune" (Pitres) ; r) fulburd,rdej.e.-.sen-s,ib,-.ilitate liu-I cutanat al nervului, dal mai ales la nivelul pr!4ulUi. gpaliu inlrtrrrtsttx li tlorsalsi ruaialcs la nivelul ta bt cherei anal orAiceff;g' 2d d). Este rf irlizrt ti.n. (piin ittir'llr' :rl' l i ftacttt luxalii ale umirului. tJau mgtice ttild lezi.ini tlr ef.'.), sau olte prcrcsParilo'e (tutnotil. brrrrierrrsuiuj

Abductcr

po{icelui

Abductor

Opozant

|^,,,*,*
Interasosidorsali Interosast palmari Lambticali iIl, IV
/ i./. 3./, NrNul cubitnl: ramuri nervoqse, distdbulia Dusculali fi crtanoti. cubitald. Crila

',': lt )

ferloriul cutand

Edial : -Fig. 2r. Nelvul r - r!ri. ,,itr Eit de lebede"; ! - Sequl ,,rasfitnni dertrelot" lF/otuettJ t , - Senntrl ,,std!8erii mlt,il" (l".ott.i,) .ulirrr rrrl.a nJrili;tl ntr se obsenl tenddN'F eteDsonlor it m.i proeminmla tadialtrhi crternj d-T.ilornrl

lr "

l,\ Iurnlizitr, rad,iata tt,Lilf,cil (aBa-zisd ,.brahialf inferioafti," a, rt'ttlo rilol rilr.ici - Riser, 1952) e;ie cea niai frecvenlir lormri de paralizirr r:rrli lit' ttivr'ltrl :r,lir, din leziuneanervului in partea mijlocie a.brail,ului, .sirezrrllii, htttrtcltr in de {rntlturi aJo rlc cazuli torsiunc a} liuq,ro Apare usului, ,"'rrn {,nlui <lo oit',ii'lu,lrtrlivl srrlui snu in diverse trnumalisntc humcra'le,la purttl,1,olii qi irr rrilcrrlrstlnfc rle coutprcsiurtc a' ttetvttltti (cltl$ica',,p nly$io tltlg ttltttttt rlo rlutnilitfi")' Itt ttt:trrtsiil' fot'ttti totrxr) dtxcuisi,rlc l)il,tts satt ,,pa,I'alizi:t, St' cnlg ottttBtrl'vil,1' plsibilfi rt i, itrI'tttcil' 1t'itttrlrsttl t,sl,9 uxIr1lliit, ir I'gIrt'rr,{'ttItt irrlrr'lI),irrr'lLrril rrrtrsllll iorric ilrrrrtrr.|t' t|||,rIt ir,||i| | |' itttllt'irtt'(llt llt,rrrlizirt ill
I li! |

Itltsrrrrolzii Irrrrgrrlrri srrpirurlor'. ll'irtell (citrr,ttkr liisor, 1952)r lirrruicir, olico prrlrrliziclirrlillii, ealr: rcspcotl lungul supina,tor' (in al'r.r,ra unoi leziunijolrso, ,rrlr lri[rrrrrll'1,i , rrcrvului) se dato]qte unei pnlalizii radiculo-rnodulxre, rrur,i lxrlirrcvrite satutnirrc sau unei isterii. i.,) I'oral.izia radiaki antebrctltialdtnaltd, este roalizal,X, ale trautnrtrisme, rl,. lr( lrlli infccfioqi qi toxici (indeosebide satrmism). Respectd, lungul rrlririrlor' qi permite r.idicalea pumnului, intmcit lezirmea atinge nervul rtrlr rrrrr:ichiiepicondilieni. i',t) ).'arulizia radialti antebraltiald, joasii este intllniti, indeosebi in rr.rrrrriismc (de pild:fi,in fracturile radiusului) qi in nevrite. Intereseazi, rll:rt lrrrnrrrilc radiale ale policelui (scurtul qi lungul extensor, lurrgul abducI()r') si (lxirensot'ulptopriu al indexului, cu tulburS,rile motorii Si atrofiile r',,trsrrtrrtivc. Tulburiirile rle sensibilitate sint limitate la o mic5, zon[ Ia r'ivolrrl bir,zei dorsale a policelui ,sia primului spaliu interosos. li) I?aralizi.tt,nerLr ui obtu,ra.tor se recunoaqte prin constatarea unui rlclicit; rnotor 1)l adducliei coapsei a] rotariei exteme a cu atro-acesti,a, lr,r loirlsrri fi plinbr-o ansteziepe -i fa{a internS a coapsei.In timpul mersulrti lrolrrrvrrl prezintii o deplasare in a,fard, a gambei qi a piciorului. Este rrrIusriprirr traurla,tisme qi la fcmei, in tra."-ali,w prelnngit, prit:' compresi1rt Lttrorr, oxclcitatii, tle capul fetal in timpul traversiirii bazinului. i'jo irnpune si recunoaqtem sindl'omrLl ltti HowshiTt-Rombarg,, realizat 1r'itr cornpresiunea ner/ului prin hernie obturatorie. ln acesta, pe prim lrlrrn sc l,flir, o durele care imdiazi, pe marginea intem5, a coapsei, atingincl r'r rrirnuru de iltensitate la nivelul senunchiului. i) Puraliziu nerralu,i crural (cu cele patr'u llnuri telminale ale se,le : ,,r'i vrrl musculocutarat exterr, nerl'ul musculocrta,n,.t intern, nerl'nl , \ r(llioepsului qi ne vul safen intern) se manilesti prin; a) ImposibiliIrlcir fbxioi coapsci pe bazil; b) Deficitul ertensiei gambei pe coapsi I , r 'i'rrlbuliili rie staliune qi de mers prin irnposibilitatea, ertensiei $erunr lrirtlrri- Aceste tulburi,r'i de staliune qi de mers silt mai mari irt para,lizin, Irr,rrcrrIIrlii, inalti,. situa{ie in care bolnavul est oltigat si-$i ,,trag[" ]x?tnlrrrrl irrfeliol in1,r'edoui, cirji. In schimb, in palalizir, troncularir .jo:*1, lrolrrrvrrlp(,rile merge, dar cu contlilia s[-Di mellini, genunchiul ,,hlor,,it" Ir ('\t|rrsilr. l)acli se prorluceflexia, gamba se derobeazS,; d) Urcntul sci,r'i1,,r crt,r:irrrlxrsibilsiu {oarte dificil; e) Bolrrayul nu poa-tes{, se rneniin.S, rrr ,,pozi(irr 1x'r'ino':; f) Reflexul rotulian este abolit; g) In lrtostaliune se llrrllvii o lxrz:i(ie cle ,jgenurecurvatum"; h) Atrofia telei antt'rionre a coaprli ; i) 1l\rrrllrnul rotuli:rn este flaso, depresibil; j) Tulburi,ri de sensibilitate 1,r.lrr(t rrrrltto-intelri :r coapsei si pc fala internd, a genlbei. Ir'ul tt'i,tt'itlogici: a) Atecliuni vertebra,le Di ale cozii rle cirl (traumatice, Irurrolrrlo1.t.); b) Turnori pelviene; c) Comprsiuni de alte naturi (prin rl(.r'lrl g|il,vi{l, in cursul unor inter"venlii chhurgicale, cind coapsele sint rrr rrlxlrrclir rnirximi, sau irr cazul purti,rli unor banclajeherniare compre,,rvr,); rl) Abccsc ale muqchiului psoas iiiac; e) Intervenlii clirurgicale pe ruilrrl lrilzirrl f) Irractud aJebazilului qi ale porliunii superioale a femurulrii ; g) .s!tnevro de rerlucere a luxaliei coxofemalale I h) Anevlisme a1o rrrlrloi lemulille I i) 'I'tr,untatisme directe ale nervului (de obicel cu cointerr.sirlcil,corrcouritontl qi a ri,r'tereilcmurale) ; j) nevrito ,si neuopatii (diaIrr.l icii, yrrtilinrtric[, toxicl). it) I'rr,r'llizirr, rrtrlvrrlrri lir:siol srrllorior(rc:rlizati (lc frr],ctnrri irlo l)Mirnllui, rlc irrrrroli rllrligrro rlrrlrirurrtiitislrc tkr iix, sit,tt lr,urto NI'nIr! it,lrr llrlzirrrrlrri, l)rin rltr i.irllul{olll in crruttl Ilrlir,tii, sltttrlrt llrr'rrllrt., tlrrcorrrgrtt.r'rittrri rrrrrrrilirll' l0tl
1

1lO COtlUl.aCUe,

lclt;i,.1rrr1r1r{,iorlrl rlc trr,vr,ilc ioricc lrrrrtitrliro{iorrso) so t,rrcrtrrolt,qillr lrlirr: r') l) inlirrLriLlrir for'{,ci rlo tbttrrr:liu .r,cr.riLltsei cvirlerr(,ilr,Lii, rulr,itr,lt,s irr l;iirrIrrl ,.ltl.iltrii 1i :rl trr,.r'.,rrJrri p'irr i rr,.I i rrIrr' ,,,r lxzin rrlrririr: p;rr.lr.:r, r{}'r:i., :rtl.,.i , ttul bulrruvrrl.1.spfiji'i pe mcmlr.rrlinf.tir.,rtllcctrrl; I'l.rlizlu [rilrrt.rrr.;rl.r ro llil(luce priu meriiul legi,nat ,,de ra!:i':. . ttt l'orali;'itt t.ei,,ul'rij,sity inleriu'(prio. fueloL.ieti,rlugili irlr.ltir,i ,.rr ,r'r r.Xl) lt tir pi,ttitltZl:t pl,,r.(,!Lcnli) prin LU,nLiit0ll.t,(.lc S(,rocUnOtstu Ji.||ll r ;r.rir.rirte,rlc_paralizj nrufchiului Jesier rnare: i,) Iicttrrc{,i1, j.krxolilol , b) Dimil-uurr'l furlei de a\-tr'nsic a corpseipc Lttzinjq ILirIir,;rr.,.:r '.)rpsAi: ,lrtr.pozilir'lczindi, ostedilicilf,; d) ln ortosbarisir uoiorn:rprczirrlir ,, lri1rr.r. LIr,lrrzi,.lo-rnhrrrri (?entm,r, componsa, $i a egaliza contrailil l,rri,u,goriislir, I,r1;\ourorcoaps-el) ; c) ijcolioz.i cu concavitatea spre pat.to|, siirriil,o;r,rii ,1, ; l) Lu{.r'sul-$i mti s,les rucatr . scirilor se face cu dificlultaie; g) Itr rkrcrrbil, i crrl;r'al, dacl se lixeazL baziul bolnavutui, acesta nu-rsi r.irlirrrr, ]oatc q|rnb:l de pe planrt1patului; h) la contraclia fesei,so remircii o itsirn(!1,ri0

. ,]0!PgratjZltlg rrLllt+j I'artant(' semioloEice :

s.ctatice in funclie d.etopograJin _prezintii,, ltziurrii, rrrri

tu$1o1 myryh1t91_ garrrb--ei ai +iciorutrii, realizincl un ;ii,ri,,,. "qr.. ',']:llt]iri" corrplct rmobil; b ) rUersd,eEte,.Etepatn f,_ ridicarea pc vi|l. tlrir.irr :,..,,,-,]],,1. ,,:.lrli'1.' bla!.1-yoe?.p: vjduri ciiciic este imposib[J tipc l .,.,.',']l I r.)tr,rtir:rv ,)u : ft) r'rrrrizian.rrotici l)r):rr' rgr a posterioaro lL uD ,llr0j _ .muqculalurii r. l.', i*rposibilitateafrexiei gambei rrr (testsemiologiic ' ' ,rrr1 aetararizi .,rl,,i'iiri ); ,.r r\ lrofiile muscdare interesor;z; ri ]r_q-Eq4gt _"lSlrscriatuxfi"-_postoriol,rd, i ,.i Inrisclrlalur', gjmbei : tt firlB'ufir-ifede scnBibilirat,. ' ',r,t'r.x s(, r.\t.rl tl, rrrl-elnlrntreguluipicior_(cugxceptiapirlii interrrcrt, l.l,',,,11'll |lrrrlr'i | .,, nri,le.'ler fir,lertle),,precum si pe fala laterald, a gamboi I t) J)c ci,lrr rrrr,r sciaIice si,,'tpnnrolc si-sosilrri-.rzjr l,llll,: :ll'l-"lE111" .simpJome t,,. I,r.irlrl
Sr : l r |'l :r .u r ci : r lrllrtri,ri vasornotorii _(crleme g,rnhieroqi atc piiorulii, tript,r, Fi "rnbritticXii -Uaf]gs ('r,rLlozir,. l, plnntare, ale pl:lii';i pi,r,, lirrrl s.d,. ). ^f" "iigLiifuii".rlce'.,1ii l , r : r r l l l | l . ] t r t,l ZtU I]l l e IJd ,cu l a f( . C i t, si i n ce l ,. tt"o n t1 u h r o . g)

r.ia railiculard, to.:l!'trqnoatqlrd'Lnutrli, testa realizrltii plirr , rrrnce ..,,_!0tl _P"qr-ol.i r, rudacinjlor,gr,u a neryuirii s,.iaLic bazin, la ie5irol din lrizirr .,l|r.rn.r.rerrnctlg4rlrq superioaTi a.go]apgqli]! Se recrtnoagte prirt rrr.rI r:i I rrr.rr I t!t::lu9togtr.. carc .rezulbS rlin palatiziei asociorea ' 'ttt( sci*ticrrltri prr|ti rr,r r.Klefir, r_t ,scrr,tlculuipoplilieu intern;i a ramurilor musculare al0-l;r,irrr , rllttur ncr\-'lut mar.e sciatic la nirelul m.sculaturii posterioar.c it ooitrl)rior :

' ,rrurtn(' nl ri tl lt ir lilr t r nor vs{, i: r t iciilr i: oJr . t r ct . t oi_lst . , icst i||: t lol, r . r : r , lur l', r l] Irl l l l tl i l nl l ,l l t i ill( r sir |t r loiir ,L0r Lni1r , il; r scicl] le in disl; ilr clt . lt).,\ l)t,r.u,licitt aointiaiWTwfiitc.Ii-iitam) 1s,i ,, ,..t,t.,,1,i tiltirtl, ttost,,ior Itt trtt' , t,t l t) t t , ) t . r . , llt J t 1, : r lizr llzii, : t r ) I r a, r , lr lizia, '1, 1. \ {) t ilt }r 1i lr ddit ct . t , ll'r , \ r r l{. |ll, i lI ||lI ir . | ' r(:| | r| I| | III,( || t {( , lt il{) t .I t odl. r , l. ir jt t r i ga. f r . r r . i ( llr . r ( }r . r ir . u .tt;rr.tl i ei ;' l i .. r pr 1'lr , r / , i. ; ! . r r r r . r i. , , , r 1, . : r r g, . . , , r i|, i, . , , 1, , , , , f , r i, , if , Li ir t r r lr r r i, l rrr| |.rr' | | || r || ,,r |r lt ir . |lir I i" : r r l) t r . i0 llUt , 1, cr c( r p{, ill [ r , r lir r st t lt t i ( I r t I iI t t r r I O t , ii .r u, \(| l l t rIr.; 1r 'IIi r . llr , r , r r r r , ; r lr r lr r riolij) i lr ) it 'r ( 'r r r r r |r . inI r l, I rrr 'I rt rr r ,, rrI r r r r

iu; fuiltt:ittc ] sint rnuit mai fi,eaveirtc,lrt(,11ri{rrl ,,|oni ttttit.C_7og.re , r'\ rr ,rcrr-L1jrc t'ru in trcimer mijlocie a coapsei fie sub ni]Iehtl tle crrrorgt,lltii r lrrtirurilor dcstiniite la muschii regiulii ]ostcriouc lr,crrq)sri. 0rr,rr,j,rrri,, rlr'ri.trtrlrl srrrnhl-ipo co..psr estein pi,rte cdnservat:i, i,r,rplriilizil o$tc(liH(l r"rr')' rir sr riirL rili irL u'.tt:xfrrl cli'ic predomini fie semnelepa.r1lil,i*r rrr, iie ccle de sciaiiopopliteu int(.rn.rlrrroiitril:rptrrtrrr . ]'.,,;.1:llllliJlll, l*,l,cru.

l{r I

poil,i,(! 1i plrlsat nici hr addlc,licr-nici" starp.cvh'firl ?ioiorrlti, (,irtor)ll ?o?t.t(r rrr lol,rr,{,irr iltu ni, qi nu poatc sd-fii fle,ctezedegetele: e) },iolta plantard esl;tr csle dilicil, de alurd tal'$3ld ; ,') Atrofia.i+telesea,za lrtllrrrsilii; d1.1\lcrsrrl l''girrrrr.rr. pl:lnla}i, rnargieiJepiciorului $i moletul gainbier; f1 'Tcndoqgl 'frint abolite l,.,lrilirln .,s1,o depresibil ; g) Eellexelc achilian fi medioplantar ; lr) { l1q117xlgigi dureritre de, tip-rne-v.riiicf ' sint destul ile frecvente; i) Une,rli xr, rtrriir.r'ci $i $tergerea lgheibulul retromaleolar ;i picior ,,in gheeri,", cu tlegote,,in ciocan": j) Tesiul lui Fromunt: in staliunea intr-un picior, tendonul lui Achile ri.mine flasc, depresibil, iar gemenii nu se contractfl tle parted paralizatd';- k) Testui ,,piciorului balant') : bolnavtl, plasat in decubit ventral, este solicitat s5, llecteze energic gamba pe coapsi- Ie partea bolnavS, piciorul rimine balant: l1)l TulburSrile de sensibilitate obiectivS, sin1, rjecelate pe ta1, plaiitard, * piciomlui ({iq. 26); m} Sopot eviden!idii [ulbur;ri vaso' ni ricrii qi trofici (edem aI piciorului, ,rlter.alii ale pielii !i ale unghiilor. ulcere l,rofice nalca-

rrr,lirl.lrrlilirr,. rr. iull;,rrr:rl.r|ii rlitr rrrir.rrl lr:rzirr 'f,r:{irrrri, ; c) l,t,:t.utnkl,iHtn(. rlrlr{rl('|:rl' r'tvrlri .L [r.s.i, r.rrrr l;r rrivr.htlrrr:.r'ii .r'rrlrilrrr.i s.iirrii.(., 'r'irrri. io:rtr'r, 1.l frr{:t 1rosl,'r (lezirrlri prirr rlnrre ir,lllcsrnt jrritr lr,l,lrrrr rlr, ..ir -currpsrri l'r ; lolrg.i ii' dupri i'iectrr,r'e accidentlalir, in trnuchiul sciiflic ir, rnr.r. , srrr)stu,nlc nrrjrtlcamenl uase, algog! penicitinii sau alte solnf,ii r:u rrr,{,i_ tttur destrucliyS a nervului) ; {} Nevrite virotice ; tN Noulopatii l,oxii:lr suu toxicoalerEice. sciit.ic poptittu i ntern_poate fi lezat prin traumatisnt c f,n x:eittrtur, _. _,..}:r,;,11 l.rltcturi lle oaselor gambei, prin tra rme directe (cu anlc ulirt, srrrr l1,t)pIdec, 'r,' r(x.r s, tr.oori pria lcvrile (lo:ice sau infcctiof,sc). j lir, lezat de obicei in tlitrrIn:ll,i$ll( . M-rrlril scialtcpopliteu rfrtet'r est.e ,']l peroneului,in rnumiJo condilji prof{,siolritle '1Y, (h rr ln(1it,,ri !"pr-tql qhemuiti.pc ,;:rrr s l.l.)-u ml .t !inc Ia pr,r-atrrJ strdzilor. Ir prrr.bctllIi rj.r_), rn nerrilc (rusicr.. viroiiro elc.). Trcbuie relinut Irr,pl ril r,:r :1,'.j'",,'*n!li rr rvtl p_opliteuertcrn por"ie fi lezat qi ilr rrod izolai; chiln. irr rrli,r, ,scra,lic rrrrr lrlc lruDcltiului scilri ic rlt u aJoplerului srcmr. reprezinti, constelalii clinice in care serniologir. sr, ..,.,!),-fI:r-l!,1::r,/ite|. ,'-.')l:, t, par'2tlz 5aL l)ar',zrrrlo nrai mullor. nerr i perifcrici (rrrrr,,rli :.i ,lirnrcnl).rptrute lic simrrlrun.fi,. sitccr.siv, drr c o rliql}ibuli{' lrrl,.,,.:r .xp.icioasii, qi nesistematizati, p.ezenfa r,nui trbk u semiologic 'rl. rrrrrlli ..ys.:l:32i. (in hrnfuicdc n.odutde instalurcpi de cv"olu(ic; rrr.r,r,, lli.: i]1..i: etiopolsgpn;., : J) llult;npwitp rirolice (prin vii.rrsrrr iL. ,t.t:t,t l:1' lrostbtttt,{j.li rr\s1ckre,tlerpes zoster, rareori prin arborrirusurir, Z) Mlt(tint, l.::.,.,',,,, . tt 'it 'tt.?l:ct, (pusivaccinrlc. po"l sero terapice ., ; rlorgii medicrrr|l,.r,1,,,, I otogp ..,:i.r..")l o:p .Stbott o [otmu a ( polineuromioz ji e, IUpUS clilr.rrr:rtrr., -r'lf'r'o(rr.lrnjo. i)o.rrartorilinodoa-.ir."ll .l4rtlti pLtrite ( n ulI ii eu ropoI i i ) ltx triiabelicr.;,n cvolul.iilLrnor t;tbttiae polfirii; careuqiaic; pr.irrr.r:irrgh, ;y.' lfl'fl|r,.)..,r -ttttrlt c(,uloli; ptxtnectpluziae (ta.rc1. t'),1'rltlrrrittle oli nearopatL p (metabolice, r.la torrce, onr.olll,irtr, .si ...,.i Ii,t l{.' ,za doltctlo tuuscrrh|edc ertclsie letrrplegicl sau rtrIiIr, totdelula cu localizale p-rerlornlnant .ct"om'effi, insolitc rto 1rIr|Ir. lrlt'gie,r'i,, iripo o tr t trofii r,scuiale," de are{le:ie osteo-tendinoasii, prccurn si rlrr l,rrl ,.. 1' .nir ] ,a lrlll:rrr rlp s{.n'rbilitalc srLLrier.lii:i si ,rbioctiv.i. cu ra_facl?r. dl. ir\r.lrr,rr.:r, rril:,rlr.rl, sirrictlic,;i eclromeli(.. ,\bscola ori"arui scim Jn h,zirrrrr, pilrrri ,lrlr, {btr r-,coldi}ie esentiali in stabilirea diagnosticului. irLrrs,,l Maselr I r'1' .,pl'rlr.rpo lulLleatrna stnt duLr.rulse ll prosiunc, iar elongul.i:l rrr.r.vilrrr. illl]gi c.l,' adc-scl, t,,'l i I Lsuporta h ili . t',,lifpyy;6.1.'.1 polinriu.opttiilr, rrrr . dc r.-grrld. nici mudiliciri :rlc L.C.H,., ','rrr1iorLa., njli t,uibru,ilisfirrr.lclir.rr,.. |,r'',i','el. I;r delrrrl pa|rliziilo jnc(? rlrrr. ii predominl la cllrenriLiil.i, 1r',r. :;t sr" \l rrdt.

,i;i='--\',',)\ --'-\:iv ttervut. dknhr ' tatirat

consfind /,J. ;,;. ti.ritoriul cuL.Luat cI anterioriai gamboi. tabloul seliriolugic ctl r',;rr,lrris,illicpnpli t(rinlcrr. din: a) Piciorcizul, halanL, iu va"rus-equtn primele falange in {lexiune I b)' Impo:ibilitatea lLrxiei dolsale a piciorulu{i a falangelor ptoximale ale degetelor I diticultal,,rL tbtluctiei piciorului; c) Imposibilitatea de a ,.bate gldsum" cu prcrorul rrli'ctrt ; rl) tlina botnafirt se spii;inL pe un singui picioi, tentloanele exten' sorilor deget?lor, ale peronierilor li tibialului an' terior sint bine proerfinente cle partca s5,]r[toasi ' (prob:' de partea paralizatS, il schimb siol $te"rse n,proba-. sral,iuoii uxipede a lui }'roment) : c) Ia de Iipsri at'elali fenurnen pingelii inapbi. qecunslald, ile ividentiere a acestor tendoane I f )Mers stepat ; q1 f mposibifit'atea cdlcii ; b) Er len'i:t de sta(iulc .pe plir'rei fahngel it I)iscrete tulburi ri senzilive,p'' oartea lat'elald,a gambei 5i pe dosul piciorultri j.Sig.ZZ.),seclelorii, r asomolorii gi trofice; jr 'llr'lieiele ichiliene Ei mediopllnlaresint coneetval''. -Factoriieliolalici rn leziunile norurlul sr'iulir pot acliona, ia nivel radicuhr (In-Su) sau Ia livtl troncular' : a) tr'actorii vertobmli sint cei mai trer:' venli (hernii diseale; morb Pott; tumori -primitive. sau metastatice ; traumal,isrne ; in ultimclr situalii, paralizia sciaticS, poate a#5rea in cadrul unui sinalrom de coadd,tle cal) ; b)' Traurnatismolo Iuxalii uur(r' coxo' a,Ie bazinului: D&zrutrrur: ruxir,lrr afecliuni ale ,, drversoaleclrunr j Si rtiverss Sl DislfibUtiesm:,,,v -'-"'-'i frrottlri a,l(l o$teo-artriti, s&cro-iliDol :tcnnrrale ; i {:(,rtrl)t'r'Nirrrri lrrnrori rllo lritzinttlni lrrrzinrrhi i 1,4f .11:.,11;'llllilf .l'lllll'.".1 ; ll rrr'r'\rrrrrrr r\r'rrru( Di'l)rrrlrr rlrt 0rt,l l .l'()i;lr,1 sllrt rlo llir'<,r,ps ,,..,,rcilnlrJ I tlivl)r'sr. 16'J

maleolato qi/sau digito-pl&ntarc). neenen 'r}a]} Patdlizia neraul'wi c.ialia poplilea entern' este reaizatd in. specialprin leziune ln nivelui .qgDdui leralgd]Li qi interescazi celqgsg m.rl.!-ch]

t j( o lDiI li( . i: : sim , - t r icli,>i put si r paljzezr . r . [ ii: ir r ti. , t , r , lt 1, l, gi, , ' (' l .rl i r.. r,l ;lu lt ir . ipa r . ir ir r elr isir . a m usculat ur ii git ului, I I lunchiuiui li rtt t r.' l l i ;r r 'r '. r liuljlgr r r ului. Pulaliziile sini t t t Jear Ln: l in. u1. il, er ll r r r r r . ii ,.rt, llrlrotr)lru rrlu\(.llla,rc si cu irnportante al,rofii rnuscula,re,dilr rii0irxll,l;ti,lr,1rr, ,1. ttrrtsivt. c:r in lcziunile tiir.cte ale pcricar.i.nului moio. rtin .oiut,,(,|. 'rrrfi'iiriir,r'c( l rrrlirrrrrirI i1i si ulle silnlroa,riie pe.icarionlllc). fieflexr,ltr ,rr,r,. l i l l rl l l r():rt(.F|lr l ( l{. t r . g lii rI i t rri t rrtIr I r: st r t r : r lt r r lit e, r ilr I l, r , ll, r r , lt , t 1lll. j lLlr . , Irl (l ' . r I| l l( . or i ir r l: r lt r : st r r t r l, , l. r rI i rI t i t rt IruI i .. Nli f r , e, llBt j, t t i l.It r i rIj r: I t [ ,rt rr rrtl l scl rl l l tt,. .Nor lilicililr t lr l cx( , il, 1l) ili1, . t , l1 sh, r r lr . isi. r i,r r llizo1, zi, r t, lalt {, ii r lr , t l t' gr"* rt.ri .r' rr{ii lir . ir r I r r I r ', r 'r r r r ir t 'ilr r {, ir r pr t r r r r r r ir r : r r r r ,r xr r lr t r nr r lir r ir , , rrrr tttvl ' l rl i gl t' fi i L'l') 'M '( I . lr I lr r t r r ,r 'rt t t t 1r k'|'r t .r |, t r rlr npLr lr r , r r rrir , iir r zr r lr r lr 1( jr ) pr r 1( ! r 1\ l ttol n)troi ]r sr . r r zlliI il 4i t l iit r r lr r lol'r lr . lr r , lr r lr {,pt il , or ir r r r r lt r i ir r linlt lhl l) 01 l ti

lrl;l

zr (lll,o I)trrliolsolxrrrirlllslrr,lrilirrrrr rlirrgrrosticului de krziunetroncularil, lr.rpr.cliv polillotroulari, (polinortrrrpllicii). Nr lilcbuio sL uiti,m ci, polincvritcle qi polineuropatiile realizaazh r lulrrrr)Nill:forme semiologice (mixte, motorii, senzitive, pseuilomiopatice, psrrurlot,ulretioe, acrodinice, hiperalgice, parestezice, predominant trofice, prtrrlornitralt vasomotorii q.a.), care ne pot sugera posibilitS,tile etiopator1r'rrilo(Iiiscr, 1952; IIareq si Nisipeanu, 1976; Mareq $i Stamatoinr llttis; l'('rrLlofunda, I976 : fo{letea, 1067;. l) l. prezcnld unui sindram poline,ari.tric (polineuropalic) cu ilrstalare rt trli. .ti. str.bacutii ne gintlim ln primul rinal la urmetoatele posi,bi.li.td,li eti,ol)trl.t)u(tn(e: r\ Polinetu'o1tatii, toni.ce {profesionale, med,iaatnentoase,crilninale, stt i r i il u,yv, eti.lice ). - l?olincuropatia etilicd, est de obicei mixt5,, dar cu predominanla Lrrllrrrliililor senziti'r'e (sublective si obiective), apare la un ei;ilic inveteratr rrrrrurli fiind pledorninant parestezic[ qi dureroash. De obicci este leltlrrrrglrisivti. Para iziile mari sint exceplionale, 'Iulburiirile trofice ryi vosrl rri,ir-esint precoce. Se poate insoli de fenomene de nevritS, opticil $i rlrr rnrrllrr ori, do tulbuli,ri psihice care realize zh forrn psihotici subacut[ rr,lrri ](ursakov (contuzie mintald,, a,mnezie,confabulalie). Se poate realiza r1i lorrna pseurlotabeticri) cn algii fulgurante, tulbur5,ri de sensibilitate rrnd:i [i ataxie. 1rrrrl * Polineuropatia d,iabetic:d, cu instalare subacut5, este rarii. De obicei rc rr:n,lizcir,zii forma cronici,. . Polinatroltatio, arsenicalii eeutd,-sub&cutd, este cle obicei profcsiorrrrli, rlstlizi mult mai rar medicameltoasi'. Apare la murLcitorii care lucroazir rrr lrriricle arsenifere, in industria pieliriei, in industria unol vopsele, a ol,r'iivulilol raticide 6i a unor insecticitle, in industria chimicd, (hidrogen rrlsorrilt, acid arsenios, axseniali). Totdeauna apar iiemne gastmintestirrillu grave, precum qi ali;e simptome neurologice (convulsii, sinthom holelilirlrrr rr,rseuical),tulburi,ri cutanate qi ale fanerelor (stria transversa,ld r, lrri .Nloes la nivelul unghiilor). TabIouI polineuropatic este mixt, dar cu lon rinrln!'a tulburi,rilor senzitive ;i trofice. lrrrrr . PoLineuroytul,ia sutrurnind,aautd-subdc'utiieste tle asemenea deoseglrvrii, predomininrl in tabloal clinlc tulbudrile psihice (confuzie rlr lril, rrrirri,r,lit rgii;atd, sau torpoare), tulburiri cardiace) hepatice qi renale, plrrcrrrr 6i tulburd,ri tligestive (clureri, virs5,turi, constipalie) ,1i hematolrrgirr (crr seinne de podirie). Se poatc realiza,Di un tablou de encefalopatie psilrolricir,de tip Korsakov. Polineuxopatia poate debnta asimetric (pe rrolvrl ndial, in dreapta) qi este predominant motorie, cu atrol:ii muscttlrrrrr lilpido. ' .\'oLineuropatiamercuiiald, acutii-sttbacutd' este tle obicei acciclcntalai. rrrr,rr volrrrlbar-suicidard,,la cei care lucreazS, in przenta toxicului: distilirlcrr, rnorcnrului, fabricarea lSmpilor de incanalescenli, qi a ampulelor' lrr,rliokrgicocu trompe cle metcur, industria termometrelorr a barometrelol ri rr rnilnornotlelot cu metclr, fabricarea sirulilor de metcut, azotat de rrrurr',ur', olorulX, qi cianurd' de mercurt intlustria farmaceuticd,(calomel,

r'\l(,t'lt)fi rtri){il)(ltt.Nr.rrrlrisl,lr ri rlo srrrrurc tlo ottcrrllt,lr llrr(xtt.illl 4lt 1,irt, ((.rrstllrtl(!rlr.r'rllrrrl0lts0 llri Jrt,irrr ;rlllrr), lotr:it'o aat,l,r:-su,lta.at,l,c (11'itt iuriliri, lrli,lol, . . Alty.1nl,,inr;u,ro1xr,lii lrr.trz'rl,srrlIr';i rlc rarJr'n, trioltoclozilfostat, tclanclorel;nn) s,, 'r.,,< ,Irr,, ,1, ,, t.r rlc (la rmrlcitori oale lucreaz:'1, ou loxi(,.1. rrrsp.r,l,ivr,) ','/rf('n1,ul aparif_ir, ri plin asoeierea de paralizii do nervj cranieni (oculrrnolor,ii oplir.i, .fi rrtolrleo-vestibulari), tulbur.iri psihicc gi sau semne henurl,olog iiur. / tulicd.fste rard. P.ealizeazh o for.nii rlixl,ri (r,rr 1rr,r, .- P.olineuropat.i_a , ,l''rrLirrllni,.r tulburririlol senzitive)qiseasociazricusimDtonrcr,rr':rol,rrr,isl,ir :rlopccie, o\ l,t,rI .altera{h uxghiiior (cu striile lui Mees),convulsii, Bi}rrl)l,ornc ;ii'rri.irhle (tremuriluri, miscX'i coreice),sirnptome psihicc (rlirrlrrzi'.rrl
l,r Illl0s1;]ce).

lblirlrrrrrlu,t;ill, os1,o J)r'orloninr[rt rrotori, Dutin(l (lobullt t)l'in lritltlotr tl,itttit'1 irr (nrrlirrl, rtttt ncttlo-trl rurrriolrgi<l tlo trntll,ittottroltlf , lt'iltlil lroplil'trtt l0{

oiirr[rl'l <[o m.ercur, sublimat). Totdeauna sint prezente tulbur[rilo (l igosl;ivo(sto ntite me,rcurial5, cu gingivild ulcerativ5 Sihilersalivalie, gonet'ale lizolrul girgiva,l),somr:olo Fi renale.

C l J nt {, {r . unlcXlnl {o llt clr ) T n( 't illi, L( . . viscCr ll, . . gr . r . r 'r t l, , , r lr . l: r lr r , r , Itl .ttt) 6i sol riologic ucur ologic ( r Lsr , 1'cr '[ r ir ser r lr r clreir ' llr ci, . r islicr r ilivt lr illo, t oxice) ( , \ I ar c5 si t r t lm ir , t oiu, 1968; gof lot ou, lt l( i?; llir lr , , 1rol i rrorl .ropat ii tt,| :.1 ; l Jr> dcclr lol.196i) . n cw"opal, iit cr . liabeli. t ir :e . r dlnic suspiciot r N, t c lolr lpr r r pr ir llr r r r r r lir r . .r' ) P -ol ,i, l rr' l ,i (. [{1,;11'1, r lialx, lar l sr ) ( l ( r so( , lxr l, ii, r lor r r ,ciir r l t lpr il. ${r nut ( , i{1 r l( , polit r r . r r |o l rtl i cr r,rttr' ( 's1o scnzit ivo- lnolr r lio ( cr r pr r xlor r iir lr r r {r i sr , r t r ilir : i, r r r r r . r r t , r r' l ti rt' psorrrl. lr r llt . l icii) , l|ir r r r r r 'I r r ist r r nilr i t , r r r li, l, it s. r r lr r r ,( lr r , lr , r iopr r lir , ) tl l l rl ' rrrrl rrl olir '. llr r r , r r li r r r t ur lizr 't v, ii o lolr r r i lr ir r lir r r r llr r ii,slr r r r r r lr t lr i ir r lil, rl r. l f, gr.r' .fi lJ"Uilor |H( l r , t l, il. ( i r lr r lt isr r r , llt ii: r ) , ( , t r , r r lir r Er rr r r r r r : r lr , r rrrrrrr' l ri i rrIrr I r r r 'I r r lr. 'r r "r r lr s, i li . 'r li'r t x I ii gr r r r r hr , i,r r r lr r llr r r r , jr lir lr , r r r r r r , r (l trl r:rl r' F l :r r t lr 'r r lr r l r r r . ir r lr r r '1. llt t r , r r t igt r t r , r lizt , r t zll I ot . lt r , lr 8r , luolllr Jll, l, t , ,

lt) P.olineuropatii i,nfecliouse. Cele mai obifnuite sint : ''-PolttrcDritucltltrricd intereseazi,in special nervii crluielrj (rrrr 1Ir|rr liz,i;r r-r'rluluipalatului, tulbur5ri tie deglutitie qi de fonai ic, rrnrxrli'r1i r,l l.qllruri-ri l'.'sp_lratorir, adesea qi cu paralizia rle acomodalic rr ;n,ivilii lrr, rlisianli,)r iar la nivelul membrolor afecteazi, indeosebi tmnclriul,ilt, rrrr,r,, ll i,lor inferioare, realizind o formS senzitivo-motorie disocialii (crr rrlr.rlo rrri rrlnJ;a tulburirilor de sensibilitate profundd,). * Polinearitu,brucelozicd (rari ia noi) se in,coteqte fi (le sortrnrl t r, irr r3'rrleqi de a,lte sinptome (heprrticcs.a.). -- Polin.e,:ritele secunderettnor beli infeclioaseqt ltt,.tl.. sild liu,rr ri rr, r(, ttlrrq. i6 noni, 1Jl l bolii d" \az:r tfelrrrit iloitli,l illi,,.\|lrrlcr r:,1i,,.,lizr,rl | ,'r irr, laludism). - Tjolintt*,itetltoi,ulinicrideb.teazi, aproape totclen'ua (1ll (lislirl,,ir., Ir,'(i'iiillne& gurii, laralizia \-iluhi lalatului, tarlburiri rle vcrlt,r,rr iri 1i,i t,,urlizilt acomotlatiei ;i midriazi), ottalmoplegii extrjnsccj hilrllllrr|r,, l:r lrr'{r s{)1rol,lsocia tleficiie:r,le memll.elol cu p}edol}l'nit1t 1ij lizorrrr.lilir. lrr','r'rrrr 1i tulbru{ri gfincteriene (constipalie si retenlie rtrina:,ii). t.'\ J'o[. 1e1 'af]alii Ttostraccbtale . Sinl I'irfr,(|osi,rrrrrr,i li :postseroterutpice trorrl)i0ii, lostselodiitelicd s.a.) qi-de obicei nri sc ilsL:rlttrzi irlrrlrrl, rrr rr i)r,lllcsa procesului a,lergic r.ilccinal sau postserotcrapic. :!) JIL fn'eeen!& unui sindront ptlincrritic (polbeuropul,i() (u .irtskt,lrttr l, nl Uoqr$iui se pun in cliscutic toatc cauzeic posibil,. lxl (,lt.o (tt,i , tll tlno|inl succint: "r r) ,Pt,/ tnett ite.le infecli.oase intri pulirr in (liscu(ie (polincvlilrr l,prrrrrurr . \,.nlllrl. polinelr'ir:r luoticu). ' 1) Potine-uropat.ii.It to.rice(satur.lliD,;, ulscnic:lli, rlt(ll1lI,iilli, 1;tli(!il ,.. rntdiclrnentoasit) lccLrrroso s{r irt lorrlor'l,rrlpr.o ,,ttllrr',1r'bon1{fi,.hllic5, l ' l {rl l l rl ,

100

sini; urttLt'rr-tiri[t"cvctrl'o doci[ so ol'tx[('lt' r:ttrtn,!iu,[,tt i\ I'ot.trt,eurttltuliiltt ttigcslive, rirrlhbsurbliYo, dc.anacidiIiirrrl ioulizittt tle tliverse ntcc{,iutLi al(oolismul .si.rrlteluLice) ':tlc i,,1,f,.j,,-rr.i"" ;i de alli -factoii (l-nulusiv grupul B qi d'' aniil^fr'lit ($oIlclea, tlh sil,amine de titttnjrt'ttil carenlc 198[,' l l|li/ i l\lrrroi 1i Siarnarciu,1968: Popoviciu ;i col:tl-r'. oe porrfn Iata unor tl1bloultctrorce dismetabolice. r't l',,linturonatiile si' ne trebuie curontc, prin ilvesi,ig:r'liile neolucidate rr,',r r',,ilL'tii croni&, si' praciicim clismetabolicu polfoeuropatii ;i gnrp de fu acesd t',',ri'i, li i rr!r'.lilrrlii si in acest sens.mai a,lesla lnillvrzlt Llnerl: - Ilolineurupatia porflricd sc poate rccunoa$te prin sirnptomatologia |r|r, rrolvo:r.sli (cLr-tlblo-uri" tle multinevrite,, uneoti l1lononerrito radiale' (sir}dr.,mulabtlominall,culatrafi' ,.v,rlrrii,rl .nt'e puhncuropatii),vis{'crald, cu pcle pigmentarecafcuii la tumina, i:ipersen.ibilitare ,,pi,ir,,i 1,rr,.,,,:i lcziuni cuLan'1tc ,lr' liIrl l'tnii,lcto'',' rc{pcctiv cu "vaccinifonoe"). gl rle t,rl,,,r'',ltrr (sinitromul uiinar'; preze$a, respectiv cleqterea uroporfirineiol qi ' rr coproporfirinelor). sint' ra,re' Amintim polileuropa-^ l'rlttirunlropatii,led,isgtobulittemice r'li.n ncmice (mecroglobu pa raprotei in rericulozele tiil, r'irrl so lof iotilni in tlisclioglobului Kahlcr).in une)elumor!-sarL ,'r"' tV,,t,i"',*inOt;i l-,oalr ri cohb., 1959; Faqon ;i Sctrwrrtz.1963; $oflct'ea,1967; Iirro,ri ,'(lltichorr t',,i,.'viciiiii.,,Lrb., 1968). Cootexiul clin!c dc srltelintti lcrvoas5 (polide leziuni multiplo oso-as.e ,,..,i,,,p,il,i,. 1ent-progrcsivi,l, osoasi, (aspectelc -hematologice, cr alterarea sti'rii in iasole late), ,,i,,,'i"l,ii caracteris(cu.spectr'u1 """t".Liale'si ineruicf Lll p"*ruot^ hipergamrnaglob 1r,""'irrl,r'll tti

1n schiml, paraproteinemicii' ili,;i ;,i;;,r'i;rrt"J; aft"osti""i ae 'eticuloza ,,tl,it'r1;a, cepricioasd',6t instalr,rea sau agra,valentrbloului clinic (cu

-mrltileci in pcrioltlcle rlie tle oijicei arimeLricd) rr,r'r'it,'tnigrlutc .1ipolineurop tliscriola"ritiiica""a ciioglobulinelor ne o.ienteazi' spre i,t,, ' ','.riii"si *""'Titli},ii;rr, nozologic incadrat de ulor sint colallenoze din, trntiite ,t,,,,,i ,,,srx,.tivlr, iulecenoz,i, (periii"terita norloai5,, lnpusul edtemir'tost derboaltr BehqeLt'a ) se io"ita, sclerodermiar rrnlurrr.rrirrrniozila, l."oLiueuroh pot insii'. crzuri-care Eristir tipici. ti*i,iu cu simft6matologia .delut& totrqi citeYr' "',,',i Sint ,.i r.r.'lllir r^rrltiir vreine cu simptoine neryoase pc.ite.ice.. Prezen-ta qi progresiva c:rpricioasi' I i'r'it,,r'ii olir'ntltive: - Evohitia gr,rtelalc(asienie, stiri {elril"e,algii rrlticrrlareqi rnusculare etc') I lr,rrrrrr,lot i,,,l,l,,itii [i" ,,rnultinevrite" capricioase 'fi,-rio polineulopatii asimetrice; 'ide obicei vascuiare) a1e I'.0. : Hipelten$iune :lrterialil' i\toilil'icrili ; de.ce1e (irr plr irlrteritn lodoasS,) ; - Semne de arteriopatie periferici' ;i, Sderin iu, lrLlscubri, (d tip Eiozitic) pe rrni' rrrrrlte ori qi cerebrilL; odiIi'"i ri rk' V'S Fl',. ale trlrrrr trlrrtLiin tlermr,mpoli euloiniozile); -Nl qi de dispruteir'emie testelor rlc ti p'ecum *i waaleriRo"e, i;.';i,,1,'1: A3l'o ,,ii', ii"i,r"Gt".torezei ; - Prez6n{,a rnod.ilici.rilor cutanate (in dermatoin sclerodermie qi in lupusul en'itematos). rrri,rzil;o, l,lxtltni itrile E.M.G. qi moditic5rile histopatologice mirscnlare, vas(in )riupriit' r'Ilr11', iLlcfibrelot uetvuase Si ale ].esutului(lt I nrn-cpidr'r'rni' ,t"uin. obligntoril in uc''rtc silr:i'1ii)-pol {i- rrril(' ,;;i.i, ' ',i;;;iil,;',;,t ""." (Dulnn, qi colab., 1960 ar b I Dtma tst (otaD tvttd ; rlia,grLostio |r.rrrtt'rr ' l(ft,lrtr6,rr, .L9$l ). pard rcpl(tti(:f'c lnl ilrrt'ic trttr'tLi llle ntl l')cl)uio ::l l,,,lintttt,,l,r.liit{' .ittiri.r,,lr,trLr'' nt'ttto1tgi.t' l'r(xlrlsr! l)l itl r:tttttltlt'sittltr' ,iit,t ,,,r,|,Trr,1,,.t,. ,r,, ttrrtrrti ltritrlilivtr, rttr'l'itr lrr r,iillt Irot'0sttl ttci,ltl:tzlr'(1 rlirtr0l,ir t,xi,r.tjilrr,l,ii l0(i

ttlrrz,r, tr.r'I lIrrrrIr';ri/srrrr r,r'r'r'IrlIiIr,, I rrir,IrrIrrIrr,, irrli)lllr{ii |r,rIrrtrrrilr,,, lxrrr,lir Ilulgkltt ;,rt.), l'olilrrrrrrrrl)itliilt r'r'lrrtiv l$or', so t({l los(1 l)iLliut{,('l)llLzictr scrtzitir,i),irrll rlr lorr lttitt lthlrrrl lrr trrirl; (rlrrl crr trotti, lrtrlor n irlrrrl,i't, lr,rl rlo ,,irrrplt'gnalo" ttcttcrtrli treoplazicl, cu cvolu!,io prtrgrr.sivir. lt) I',litturuyuliilr tlcgru.cruti,rc. Aoi so inculrt'azir ir5rr,-zisir ,,1r,/ilr, .t tt it,i" hip, r(n,.1;,.,i tamitiali ,.r c,./piliti?; (buofu ly; D(jlrin, sutt,tx\ rrlulttr(ti (t;ptil, lt;dpsi tourjttrr). SiLr b4li dcgr.rr|r':rtiv| ril l' rl ',\',trrlir. Irrgtcsi-i'r'i 1r , in care atrofiile musculare cLrdebut distal itiiing ilr rrlo(l In)A11,. sir', in tlectls de ciliva ani, toate cele patlu rncrnbre (rlul x,slxrclii r.orr;r stk', bra,lcle,ct'nl,urile qi fa!a). Se inso(escde mari tulbulriri rlr scrrsilrilr lrt,lc do tip ectlomelic, cu caracl,ererlisociate (cu nlaforilii hiporrslr.zir', ltini )r anestezieprofuntl[) si eu mar'e atarie. Cel rnai iiilescrilrr,rli'lrrrl,rrl lr'rlii, b,rlnrrvii acuz; si clureri fulgurante. Un simptonr pirlrierr0l 0rrir, ({'.rt'.l)crlnitu rli:lgnosticulfftti r}e ,,tabesularniotroJic',)il corrs1,i1,uir, lrrgr,,r liitile foarte ugor palpabile, strlr folni, de ,,mitrinii, r]]r, 1r'ul0hilllill r(.r'\-orse,crlc) itr intregime pot fi hipcrtrofiate. Sint prtztnlr'lrrlr.sr,rr 1i l.rs.ir'uhlii musculare, c-ares6 qtie cd,"sint,cu tolul excepiionrrlr. ir rr.lr,,i t,iile pe.riferice1ra D) Poliracliculortr:rri,tele realizeazi sindroa;me senzitir,o-rrr o1rir,ii lrilrr lrtale . Di.sirnetriee, cu diBtributie atit pluriradiculall,, cit si (rl,rr)tl('licir, rlo obicei foarte extinse, putintl gelera tablouri paraplegice sur rrriri rll ut abi1 .tetraplegice, cu axeflexie osteo-tendinoasi,, cu nrlrt:lti Iripolorrirr trrtsctrlari,qi cu atrofii precoce gi lapide. Sindromll ile profouelrrrrr sr,rr z,iliv (cu tulbur[ri globale de sensibilita;be) ptezintii aLeasclnclr{,1 ilt,tt ,r rlistt'ibulie poliractricula,ri, clt qi ectr,omclicl. Cel m:ri iulesea sc li:(lclr,lzil ;i trlvii cranjeni (perechiie III, Itrr, VI, Y motor, VII, fX, X, -\t ;i I I I ). ill,rrlilir.r'i,rile lichitliene, cel rr..u i ailesea cu disociatie albumin*r.ilol rgir.ii, r ir r'i palafeze diagnosticul tle poliratliculoncvr,itir t.irrillain-Ila ll'r.

I +.

PROBLEME DE DIACNOSTTC Itr TULSURARILE TONUSULUI MUSCULAR

4.1. HIPOTONIILO MUSCULARI' 4.1.1. Hipotoniile t/anzitorii, paroxisticcse caracterizeazf,, ptin bruschcfca cle aparilie qi prin tlurafa scur.t5, (citeva secunde sau
| | llI l[ e) :

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L) Atacli cala,pLectia consti intr-o pierdele brusc5, drarnatici,, a iorrrrsulrri muscnlat qi a motilitd,lii voluntare qi printr-o pritbusire ,,posirrr:rlii') ca,re cortrasteaz5 - de obicei - ct perfecta csnseryare a conqtir.rr{,t,i (.Devic qi colab., 1967; Popoviciu qi colab., 1978.; Rechtschaffen qi l)crnrrnt, :1.967). De fapt, atacurile catapiectice apar in mocl ercepliona,l izolrlr', t'lc nsociindu-se, dc reg'Lrli, cu atacrrile narcoleptice (Yoss $i Da1y, lll{iO; Popovioiu qi colab., 1978). Uneori accesulca;taplectic poate fi pre.rrr|rl, rlo scmne premonitorii (senzalie dc oboseal5,, de ci1,lduri sau ile r.r,rrrI,r'ic|ir,ctc.). Inhibi!;ia tonusuhi postunl poa,te plezenta intensiti.{,i rr|Jirrliillr,ric ll o hhibilie total5,, cu clclere (mar.ileacccsocataplectico), tonicX localizati, la ta telitolin rnuscular (crizek, lrrrrrrlrr o rlirnirrua.rc r.:r I rL lrl00liIrl pirrlia,le). t) l[r.uilc urcesecataplectics su,u atacuriie crtaplectice severe (Dal.r" 1i Y oss, 1l)?it ; Corfariu gi Popo.'-iciu,19?3, 19?4; Popoviciu ryi colab., ll)il{; Irolx)r.i(fiu, 1,979)sint tipice ca rnalifestare: in rnod b|rsc, manctipleoapelese inchid, capul se ilclirri, lrrrlrrlu)rolti, gura se intretlesohirle, pr' lrir'1i1,, lungul corpllui, obiectele cacl dilt urcmbrele superiod,recacl c1e-a, rrrrirrii,gcrrLrnchiise indoaie rsi bolnavul sc pri,buqeryte. PrS"buqirea este, rllr'i. r'rrpirlii, (La,r' nu instanNanee,brutali, ca in epilepsie, ci progresivi, Irrpl lritll'inl penl,ru sttubilirea diagnosticulli. Fe de alti parte, bolnayul :lrisl;i rrrrrlt,ientla at'acul siu de ,,pr5,bus,iret'caiaplectieii, d:rr r5mine de .lrilci corrrplct irnobil fi afon, ca intr-o staro tle ,,cLuarizare" si inccarcil'l rrrlr.rir.rr o sorztl.,ie de neliniqte,de anxitate. Uneori sepoatelcln:rlca : rniozti't rl lrrlrisrrr riivclgout, mici tresi,rlri mioclonioo li, cxc0!f,i{)na1, rehxir,r'j rrf irrriclirnr, Sint 1i cazuli, la care inhibilia motiiiti,{'ii Dn etitetotu',li i}bsoprrl,inrlLr-sr: rr,rulr,lcir,, Irrl,r'i. in culsul clizoi, rllioi rni6ciiri lolutttlt'r:, lititil;rtlrr (le ll'tic,ltlrut(r posjl'jlilrlti pirrtirrl(r pr?lrrrn 1i orLrocirlc 1r, lrr rrrr'loi,r,r'i|,rrlii, rlr, olricrri turitri;cligilrih,. [n lirrrlrttlt'tizci sl irttttslltlii:ltilto' rrtr,r'r'ttvinlo,
Irttir lf ill * rrttr,r'rrlizrtlri. r t lt olit r r t t t o1|lr r t ' k t t r t t loo l l t t r l i l t o i t s r ', r t l r o l i t t . 'l l t r 'l 'l t r -

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iiilfril;li:t i,r,ir[ iliiillilililifriil;i: il,llin;f l*-irui

r'rl,ir, rrxir.nrtllri,lrrlrtavul lrlozirrt,ii l,m'rrspiratii ;i poliulie' '1'ottleilutra oslo tluretoasi|ryiin tirnpul crizei se cYidenliaz'i hipokaliemia' rrrrrsrrrrlrr,Llrli| in sr,hirrrlr,itr palalizia perioclicd,familiali hiperkaliemicd (boala lui Garni,,i,,, ,,,r"t.,,o',r dc obicei ilrlc ..,si 10 aui (90% din crzuri;, se dcclanduph inani{ie qi dupd' iud, os,bi ziua, mai alcs pe nemiD.cate. r,:'zi' I'r'rr,,r,, pe mu$chii cranieli' predominind paraliziile ,',1,,r'r rri rritrsculareintense, r,r:izci se constat[ d cre;ter" lr$oariia ionului de K+ (crr rnetlie.ite trr I irrrtrrrL de I 3 g de CLK poal" fi piovocrfaprin adtrLinist'tarca ', ','l;,,'ir. t iizr, pruden!d')' efectuat cu trebuie insi, rliiglostic. iare rtt r, r "igrir pierdere printr-o brusci a tonu(lri'.rr de dt,m atlacl: se mlrrifesti lt\ este bruscr f[r6 l)ebutul pribuqirea, bolnavului. ,le . rrlrri rrr';iutir[, tu,ritii rotaliei sau extenin timpui pro{luco de obicei r-Lltr se ,.','1'..' 1,r,.,,,.",sr:rle, r,i rtu se insulrq1ede pierdelea cuno$tintei' Auzul, vederea qi r,.i ,,.irrrrlrri , r,rlriliir rLttiLl lerltrtlte. i'riza cle drop al,tnck este un simptom al insutilicrrli,j r,irculltl,orii vertebro'bazilare Coriariu, 1971 ; Kubaia qi Millrlirrrr.l1){il; llopoviciu si co1ab.,1968; 19?6, 1980)' Diagnosticul tliterenI ,,rr , r,zr,lt' epileptice akinetice (amiotonic-llkinetice) se imptne tot,l',' ,.r,rl',r.ir, nici rlrr crz nu se evitlcntiazi modificdri -tlEG dc tip epileplic. nt,,,fiti,,iirilelillG ale atacului de dlop uttack nu pot fi suryrinse, din c\rmeaul necesart I,rr, irririrnpli vizibiJici!ii epaliriei crizei,rlai 9lFG esl" i,,t,rr,rt nu.rl, evidentia oar"cate anom:lii clcctrograIlceca'racierislice r-ertebro-bilzitare (PopoYiciu si colab', 1968r 1976r 19?8t rrrsrrlilit'rLi.ti | 1)r'i()1, l'l lr)ristii' ft,rine dc cptlepsie in care dominf pierderile tonusului de " (cpilepsiile ,,siatice" ale lui ll,amsav -Elunt, crizele de petit ,,,,tit,rrilin, 1,,,,t ,,,,,i,rtonici-akinetice, crizeie epileptice temporale amiotonic-akineri,.,, (itstaut 1i colab., 1969; [iastau-bqi Broughton,. 1972;. Gastaut' de obicei Cont ert ul s"miologicne orienteaz;' )viciu ii colab.,i 9707. l :r7;, : I ','r), foarle frecvenLd .,i,, i,r'rri. l,...lnrctizoi, r'tt dttrali scuuti, prin asocier,'a de obicei cle tipul ulei obnubi]iiri sau absenle' l,ir,r'iliri conltiinfei, lr, pllt LLr -pdstaccesuale, a amneziei accesului si, mai ales, ,, '*iii i'ir,,' colf uzionale IIEG qi pohgralice din aceste crize' rrrrorrrrrliilr Gt I'truLiziile dP sontl (paraliziile hipnagogice,cataplexiile hipoe' sitrt' in realitate, ,,,''r(r.iirlr ctlt.oleliile cle ,,aclormirc"sir'ude ',l,rezhe") generatS, cie structumusculari prin inhibilie .*,. musculari, ,r,', rr,t,'rrii ii,.il ,iil,, .,,,nll,,ni,ofalice ale sistemului somnului REM, apirind de obicei la Eis^hikawa irolrrrrviitttlurleptici (Daly qi Yoss, 19?4; Yoss Ei D3'ly' -1-q59; .i ,,,r,,n-. lCoir:- Pompeian6,fOOZ; Nan'no ;i colab.' I970; Cor{ariu 9i i',,.,,'i,'iir. f974. 19751Popoviciu ti colab., 1978)' Trebuie d iferentiatecle ,,,'i,r,, r,,.'o" tte cpilepsie rnolfelcd, prin inYestigalii EEG qi poligrafice, in tLe sodn iecxisthcl anomalii EEG, in alarX de contextul poli,,,,,,rlizi,l,r arlti c5,paralizia de sonl, fie in forma sa izolatd" fie la narcocir,tt: r:r"r,lir,, icrrl rci^ implicri aplrilia inhibiliei musculare caractedsticai somnului R'EM' (Nan'no qi colab., 1970; Cor1ul ti,'gil ,ri, fulcl tle ielativS, stare de veghe frr,r'irr 6i lbpoviciu' 19?4' 19?5). 1.t.2. IliPotoniilc durabilo : It) II iytokniil,a lqnarllisate sint raro: r,itn $o llll'ilno$l'o (rtri]lrtnkt') mn!/ ni.lald'a ltti Oppcnh L M.iul,uniu,

lil', t t,tf,tl t' i sl ,i tl igrttrrrrrl o x l l ri ttrl i i ,, tl i t' l I' i i tttl [l tl t,rl ,tr lrr,r'rrDii.r r lolr ir r ,t r t il|t ,,ttl :rl l 1 I ? {l

r.;rlri, rriisr{i,r,i rlr.;rrrrp)o (sin1; rrrsir,-rrrlrrilii 1rllrrriIirirI llrrriv, rlr',rrr.lril ,,r,oprr rlc lrrrrcirtci' liiset. 1952). :!nta;ine ( atrofi,i,le cerebelo(s(: ). l:t.lt'r i nlcl.c aerebeloase ;i. Iltt(.|c tl.is{rofii musculat e progresire. 4..'l's,besitL(forma amiotonicd,). B,l J{ipotoni.ilenzo,imulNsall mdi gtulitr,locali,zate (tle 1,iplrrtrri;rl,gir,, ale corpulrri) rrlrrrr.irr lrrla,piegie,l,etraplegicsau doar la citeva se,gmente ,rrrrrilr:,r,'lt. s;lual;; pulologice : 1. ,ln- najoxii;atea cazurilor, hipotonia se instaleaai, brasc 6i esl,c llrr liziil,ri tle Le.zittttiale aroalui refler toni.gen, respectiv ile leziutii ntrtlultn. ,.,i pti,Jerice. Aceste tulburili tonice prin atingerea arcului rcfltir lorric 'Ir.rnentar sint totdezruna iinnitate si segmentare, dispuse dup5 o topoglrrtrr. L rrliculaRi sau tlonculari,. Se constati, qi coexistenla trrlburdrilor srinzilit'r,, t otice qi paralitice iar leflexele osteo-tendinoase sint abolite (semtr li rirli l :rrportant). Ilipotonia este cu atit mai importanti,, cu cit lcziun(fl, rr,lojrl rirri bnrscl. De pildi, sectiunile miiduvei tealizeaz:acea mai masivij lllr , i(nte rausculalri, ct topografie paraplegici sau tetraplegicd,, a. [,eaiunile merlulare antrerreazl simultan hipotonie pin[ ll lllon il tttusoulari qi paralizii (de tip paraplegic, tetraplegic sau mai rar mouoll(lfli(). :l\t'&,rlrnatism?.[e medt are (cu secliuni complete sau incomplctq t,vcrr I rriiI prin comolii medulare ) qi lrcnzatamieliarealizeazd,paralizii hipoi,orrir,,, rrrr atonice imccli:rte, de tip para sau tetraplogic. Adesea debuteiuii ;rr.irr il o fazii de +oc, insolitil rle un raasiv deficit motor ni atonie crr rr,i'|,.,,,. rrii ri r rr ' rslco-fendinoase !i critanate abolite, cu incoltinen{.I sfincl,cr,iu rrrrrt'i tulbur'dri de sensibilitate. Aceast[ atonie musculari in ]eziurrikr r rir.r I rr lrr'c masiye persistf pini, cind se instaleazd, ienomencle de aul,orlrr,i,isr rr rrrrlulirL, cu respcctivele simptome de elibera,re, cu sincinezii globrrlr.. lrr , rrlsrrl compresiunilol medulalc br.utale de diverso origini, sa,u irr lrrzrrl riror'frpctiuni spinalc incornplete,se observS, adeseoriacelagidcfirril,rrrolrrr,, rlrr trr hipotonie mai pulin marcat[, qi mai pulin clurabili,. Lc;iunile medulara a.arle nelraxnn(rttce tealtzezzd acelaiii sirrrllorrr I'rllllitic cu lripotonie. Itste vorba de m,ieliteteaar,tetransoerff $i rlrr 2,,/r,, ttitlikt acndd,, in care palalizia hipotonici, qi aretlexicriltlotniiri 1:ilrlorrl ' iirric:! 0u topografie tetra- sau paraplegici,. ln ytoliam,it:lilele subasute sau tw instalareprr.rgresi,t:ii, pc prirrrrrl |lrrrr r r srl,ueazi,paralizia atroficii, hipotonia {iind ins[ nolipsil,il. !, In compresiuttiientetlulare progresioe (prin i,umoli tle rlivei'sorr:rirrli, rltcrxe, pachimeningitii,,arahnoitlitn q.a.) hipolonia^cstc rilrtxl'i irrl,ilnil,ir, rlrr obicei constatindu-se contrlcturi musculari. ln scliimb irr tir,irrro trtirrlieqi in tumorile intramedulare, leziunea, pericrliona,lrlpoatr: llrirr,rrr rrrci, de la inceput hipotonie muscularl. 3. I'eziunile progresil)e spinala posterioarepri,n leziun i ale atnlaqntlrn. lt,tsllrioare(ale fasciculelorlui (ioll qi Burdach) sa.upr'in leBiuni r(r(li(ut(rt de tsorn(lnoa, lripol,onii plin inl,elfln:treil u,tt'ttlrri rrrlh'r loxtarioarerealizcazd, lr)nl{r Olementiu. a. ilipnl tt,<)ostor rodidllo 'm i(lite poltlffiaor,r.restc rr,prtzlrrl,rr,l rlrr lrrbrl,nlti nkrsi rr ril,rrt{;ii lo cu irnpoltrrrrtrrtull;ulr1l:i r[o stqr si]ril il,i!1,{r lrrol lrlriri,. b, H i.rul;uq,nt d,t' r t Jihrr lu,rrgi (dt. .nr(loun( Ttuslrtiourt,)?v:u.lththr ,r'r'{r intnlll('iio lul (x)ut,(fxl, rr.rrriologir irr t:lrrcpc 1rt'irrrrrl pllrn sotr,l['i, lrrllrrr lililo rlrrptol)ti()nr{{rl)( i{r,rrr ;rrr,llr.lil oslr'ol,rtrrlilo:l,.ll i,ricrr lriprrlorrir. rrrrrrr lrrfrr.rii. r.sl,r, Adctr,lr, vollr:r tlt'ni itou. tt'd( ttrlu t)tii tttuhintlli, ltr lrrrr. irr (,orir,\lul clirric:r1lrr'4ir, rrrrrr, f.{r'girrrlitrr,irr :rr.r.nlr. rrrlrrlrlir, 1rilIrrrrir|Irlrr. t7l

com'bind'td carenlit' sindroamele tle salerozd, \t s irr,rLl'ou,nte l,e n'au,ronn'ent,i,.xt, (indeosebi eredo-ataxia sau ;!'a i nrtcer,ebeloase sp d'egeneresce lrr, rrtrolo liolri, irorrJrr, hLi I'rieaheich) (majoritatea rlegenerescenlelor spilo-cerebeloaso, irrrlrrscbi eele de tipul Piene-]farie evoluind, de fapt' cu spasticitato folTa pseudo-. care teallzeazS" Rareori existS,scleroze in p15,-ci lrilrrrrrirlnld,). profri:nld, hipotonie $i cu de sensibilitate i.rIr{'l,it,ri,, cr marcati tulburare in cate qi semnele cerebeloaseapar ceva lrirr,rrr.Il,i.,rie osteo-tendinoas5,, rrrri litziu. .1. t,a: tu'nil,e periJeriae ale orat'Iui refLen c\7 hipotonie consecutivi', Polirad,i'culo-nevdte ; b\ Polirrrrrl,irrl,ilrrite in iumbroase afectiuni | ^) (ve capitolul precedent) ; ttt t,ri:r'.ni ttoltttcur oputii il'e diuerse origini, metabolice (tlaumatice' torice' , ) V,,,,r ift,' si neu,ropatil. $.a.); d) Leziuni
, ,lt pl,.ttt1 ilt,i

pi1t15 in distro{ii1eilusculare plogtel. Alealiunile rlasculttre, ca c1o importante, degi :rrcul retlex (rrL irxtaleazi atlofii se ri.rzulilu in c.ne ; ir,.
r.ilc

llrt,rL ill,

lot nbar '

o: r c r aL) .

0. It;:tutlilc ftttmaliuttllor cu acliune Jaci'Li.latoareosupta dtaxt'lui' ( prin intemediul sistemului rei;iculat facilitator tlescentlent), t t llt ,t)Lt)tLioen i acliunii forsiirr,r(ii iricLr,rJhipotoniamusculard se datoreqte preva,Ienle : rrr:rt irrrrilot inhibirorii etescendente (infec-tioase,traumatice, degenerative, atrofit\ I'eziunile aerebeloo'se ilr coictreloase cu tliversele lol forrne clinice) se pot insoli de hipotonie o rrrrrscrrlat'd(uni1aterald, sau bilaterali, erentual crr predominantd' 'le a p: lu), care se poaLe evidcnlia, pe linga-ptobele clasice de e:.plorare proba pasivitdtii a' lui i 'r,,ritiiziliipasive, qi prin allc probe senriolcgice: remarcindu-se bolnavului, pasivS, a tmnchiuiui (dd rS,sucire Tioriias A rrrlr'6 rrrisciililo rnai ample ale bia-tului de paltea hemisindromului cerebelos) ; prolrrr, ,,r'ezistenlei" a tui llolrnes-Ste,ivar"t; proba reflexelor pateiare qi "'o"ttlll^rl;r*,*or, neostriate (coreile tle diverse tipuri qi etiologii, acute qi caracteristicS, hiperkinezia asooiazS, crrrnicol sindroa,rnele atetozice) variabile. rle iltensitS,li lrip,rl,uttia c) Llnale sind,roatnaaesti'bulavese pot insoli de o discret5 hipotonie rrrrr*r,rrlrrlli insilater ali leziunii' d\ It l&lunite neuron'ilor tnotori'centrali, hipotonia muscularS, poato numai in situafiile in care sindromul piramidal s-a insbalat Hriti(' irrl,ihritii, lrlrrsc.dlr si il accsle cazrrri hipotonia dureazi doar timp de citeva sdp(sindromul piramidal deficitrirrririi.in cale asist[m la o hemiplegio flascS, piramiilald, c&racteris' hipertonia instaleazS, dupd, care se i:r,r:rl iui Barr6), l,irrr'i.Nlonfioni'ni ru:rele parali.ai'i fl'a,ececentrale pseud'opariJwical -inso"litg si rlrr u,1,xrliimuscula,re, adesea cu distribulie pseuclora,tliculari (dar fd'ri (meninfronto'parietale d.e tumori unele rea,lizate ii. | ). ,r,,,tlo*usculard), giorr,rno,glioame) sau de suferinle vasculare.

rllra,t,t),

4.2, HIPERTONIILEMUSOULARE 4,2,1. Iliporl.orriilo plroxistioo sint roprezentata la diversa crize de Iitr orrt'pul ln int.regilne, Iio auumito scgmonto (ont,'tu,hffd,cliro inturosor.tzii, lrr Iunofio i]o rnocllnigmulcontnlcburii' u, oor.Dori0 ii:ola,to ti oi"!l'ol'durlll,iir
t{ll,ll (l(l i)l(1. rtxl,0 <1()tl00Lttttlr.}-tttittttl,o, l't !,

4.1!,1.1 . I l ipul,otti,il.upu.rotittl,itl rtutt,r'ttul,izttl,t: |) lr'onnt:ltLort,i,r qtik4tsic q(n,arlizal,ii (glarl rn:r,l}r,irntr,r. d,r: grrrrrrr,ll'li gonot',liza,1;) zirlritl,u $ootrtr(lirl sint rcl ,tiy nryorrlo rxtnrroscrrt, prilr lrrrslr,,n. rlrrrt* bruscil rr,corr;Liorrl,ei, prirr carrlr,toruloonvulsioi i,oni(x), l)rilt {lut,t[l,n sorrrtii (minuto), prin tulburf,lilo respiratorii, vit sor]ro1;ol'ii rlo a,rxrrrrprrrri rrrnonl;, plin ernisia dc urin.i in crizi,, prirr mulscaroa lirnbii, prin prrrzrrtl(,rr, rlo ottioei a miclrirlzei qi prin surprinderoa moclificririlor lrllr)(l (Ar.sorri [i , 1978 colab., 1970). ; Popoviciu .,qi "lrb., lr\ Marca crizd piliatici poate sd, realizeze o corLtrrrcitrr,il, grrrrrrr.rr,li zt,bii, da,r, spre deosebire de criza tonicd, epilepticS,, ar.eo dulttii tnli lrrrrgrr , rru se insoleqte de apnee, nici tle emisie de urinI qi do mursclrrlr,lirrrlrri, rtioi de sernneEEG, apare intr-un context psihic revehtor., illr.sirrr;rl,rr rlr,l,ologia critic5, este ,,neulomimetic5' t, adicil, are o topogr:r,tir: cN,r.o rrrlrr. sj{)ir {ru colespunde structulilor anatomice reale, ci ,,itleii,, 1o otlr lrolrrr, vul o are dcspre ,,organizarea" Ba corporald,, creintlu-se zr,sblirlo Irr,lsrr, .,schem5,corporald,'J (Enitescu gi Popoviciu, 19?8). c) Tetani (si sind,roamelespasmoJil.ice) pot s5, realizezo (x)trl r.rrrlu ll spasmoclice ale extremitd,lilor (cu spasm carpo-pedal, minil rlo rrurrrro4 ii cu planti, excavati,, cu inclestarea pumnului), a1o trunchiului (orr rrl,trrr. ciri ale torsului), ale muqchilor felei (cu,,ris sartlonic,)), spnsrrLtr orrrrkr rrrotolii, ale limbii, a1elaringelui qi chiar crizc tonice gcnei.r,liia,0orkr lrll r.t, pscudoepileptici,(Riser, 1952; Figi,rd,qan qi Popoviciu, 19?8). I'rr,zr,rr(,rr srrrrrnclor lui Chwostek,Trousseaugi Erb, lipsa pierder.iicunosl,iuf(\i,:lrl,(, ,.rl{lontele, modi{lcd,rile EEG qi EI}IG (1a proba g:lroului), motliliici'lr'ilrr c:rl lcrrrici qi/sau als magneziemiei, clarificd, dlagnosticul (f ir,glriiqrr,n;i l.,opo virirr, 1978). deJosiiposterioariiau fost ilescrisc inilial rlc .lrrr'lisorr ) Crizeletronice (ll{?1, oitnt de Arseni qi colab., 1978) sub termenii cle ,,cercbollilr.lilrr", seizurest'$au ,,crize postedoare,t.Apar mai:llos Lr,r'rrpir ,,l,rlrrrnrs _like rr rr l:r adulli tineri, in special in tumorile mecliane cle fosri,lrosloliorilrr (1rrl,po un pulrti,.r,i Taterial de 1040 caauri de tumori cle fos[ posteriorr,i.i, rlr, Arscni gi co1ab.,1974). Aceqti bolnavi prezintii de obicci ;i |i'rrorrrr,rr," rlo Iripcrl,ensiune intracraniani,, insolit5, adesea si de o r.cclo:lrol i1(\l'(,ilr :r lrrhisului, precum qi d.e pozitsia ,,ceremonioasi," a tnpultri. . ln mod brusc, de reguld,in urma unei migciri bru;tu a ca4trrlli, col prrl se plaseazd intr-o contractqd, tonic5, in extonsie, in opistotorrris, irr,r. rllpul este.aruncat_inaloi, eu ochii deplasali in sus, mcmbrclo liinrl Jrlrisrr,tr, irr lilexieqi pronalie. Uneori se asociaz^$i trismus qi incontinorrl,rlsf irrll trrrir,nir,. devin-e foarte neregulatH, qi supcr.ficialtr, stnt (lr! i,ill ^R,espiralia t llrovne-Stokes, apare bratlicardie, pulsul este filiform, bolnrr,lI I'jirrrlrlorri. rrrroori obnubilat . Criza dtreazra do obicei clteva minute, putind I'i nro r,l,rr,lil,. t)rr!ir, .crizd,cefaleea $i vd,rsS,turilese intensificS,. S-au deicris qi lonnrr pn.r l|ak) da $tza tonioe, caracterizato doar printr-o contracturfl ;la,rrrxinl,irrrl, l rxrfci, sau a membrelor qi a oefei, dar nu lipsesc aproa,po nioiodrt,l,it, i'trllrrr |itrile r'<lspiratorii, paloarea qi cefaleea. S-nu descrisii crizo tolrim 0rr prrrrlrr nrirrrrn(;ir, unilatcrali, cu asloct rlo torsiuno a,xirll5, (Va,n Boglorl;;i Mur'l,irr, lll'..11"t, oilrrti d.o Arseni 6i oolrr,b.,19711). Mrr,ioritatolr, ir,coslior orlzo l,lrrirr. trrmorilo rlo frrstlpostoriotli'i,(inrloosolrivollrlt,lr\) rirtI rryola,torlropontr,u. rii ;rorrl,r'u nngt.jfi,rilol;errrpor.llc, t5i r.lrtrrlo l,sl,lilldo rlrizo in ctr,to so H1ill1,1rlr.i trrrrr||;iot rl,rt tr.rt 1;r'rrlluio rIIrrrlrIrrrIr11;o 0u 0r'iz0kr rrpilopiirrrr it)llir{r(li,iHr,r', l0ltll , Atlotri qi rlrlrr,lr,, lll?lt1 Al'Horri tl {!lrrt,{!,rto II il(,I rIr\I| |\I|, 1i l'opnvilirr, l{)Bt)), jf po;rl,o lrrliltti o fi{uttoltrfn, r.o ltrr,tll, ri, I,rrtrit,il, itrxlrtil,iL rltr rrillrrozii, 1i rlr'
t i/ ]

rrirl'iilxii. l)lr', irr.lr,llr rlr'lrrrl, rrr i'izrr r.1riIr'1rIr.ir, s. p|0rliic0 o rrl)lr(,(,, ,lrrpir. r'irrr.tr.,pir':r{iills,. -rr,r:r.rll,rtr rrrr,rJ rllsl rrl rlr.r.r,j{ul;rl, I,r,Olurrd(,i, ,{r'r'l()lrrir'slr, (1lrt(}frd (lii(i'iL(i do criz,, tonici a hri Jaaksun. -tn schirltr, .rr.r.il. r'r'izr. lunice tlc_Iosii, posterioari, cu rluratii de aBerncnea Bcurtii,, nu .,. rrrr lr..r.ttc.obit.ei tle pierdoread,. cuno[tlntr] si ecl rnai tdesex dispar rrr ;rozilicde decubit dorsal (drs.ri li cohb., 19?8).Arseni (1050) a einis i.,r'ir v.'Lricu1ari, confomo sireiir aceste crizc se produc printr-rin rueca.rrrsrr rr'1icula,i, ceea, ce erpliri qi_fuptul de cc lrcesiecrize-pot si, apani in IrrrIr: pr,ocosele patologice care iriti perelii r'e1}triculari. t,) 0.izele h,tptertonice d,in letartostlcbtteazi, prin trismus gi ris salilonic. ,lllrir r.:rr',. coultactura segencrrlizctrzi,cumpletixdu sc eu rerlua rea cefei, , rr rlivr.rsr. inllexiuriiale trrnchiului (ir:ainte.inapoi ;i Jat,.t,al), clr reduareJ rrrrrr..cl_rilor, tlrepli abdominalj si a muSchilor pectrxali, plecum si clr contrac_ irrli alt rnembrelor. Aceste hipcrtonii ttanice sint pielungitg persistenie, rtrrrl'roaso, fiind eracerbate prin paroxisme tonice vioientii initise ae c"*ij l:rI ii scnzoliirlo si psihice (zgomote, lumin5, emotii etc.). t 1 .7 t urb.o r e apar conrracLuri bnrslo I rringo-tarjngu-d iafr.aema I ir"e, .t ,t(.,,.,.hir d,. riolente..insolirpde cri"e de apnec $i ttc blo'cajlrrin;ia;; itiI l.rrlrr,tivtde deglutilie a;ntreneazi, desciirrca.ri tonico-cloni"ce ale*buzelor. -de faciali qi ale constrictotilor faringieni. :rl. rrur;chilor Ca gi in crizele-cliri t'.l, rrr)s,acoste conlnacturi tonice rabice sint, in moil caracte'istic, declan_ ,rrlrr ii .xacerbate Ia cel mai mic zgomot sau Ia eea mai micii rniscai'e aol,iv6 rrr.rr llilsivii, ,{1it crizele tonice <Iil tetanos, cit qi celc rabice, sp iusolegodc oxago_ ttilet_telor idiom, sctrla,re, ostcotendinoase Si mai rles i unor rofleie 'rr.r.ir ,lc llrrnchi cerebral (nazo-palpebnl, mtscter.in, Chwostek). t) In intonica!,ia cu stricwtnd (sau, tn su.pradotareaterapeuticd) poate :rlriirtir ti sttire de contracturi d e., tip tctatic, cu t,rrucorb[-l.i p""6rliti"e, . :',i, .,':r r,llorrrind crr convtrl;ii clunice_ 'f .i!.1.2. II ipertoniile paroristice localizate t) Crizcle epilepslice localizate (tonice sau tonico_clonice) tle tio iack_ rr'rirrr ((,u f.i1 fii,rd lierderea de cunoqtir-LlL,cu sau fi,r6 der-iatia'cilj u_ ,lrrl.rr rr r.rrpului$i a ochilor')se recunoscprin durala lor scurta, uneoriipie_ lr.rlirrrlo crizii generalizatl, precum [i pri]r contextul clinico-EEG. ' b) 'I't:tunia ;i, spasm,oJiliase poi manifesta printr-o crizd, de contr"ac_ lrrlii.lirrr.itiiti la un segrnentcorpoml. Oontextul clinic gi EMG o" pr..izr.:rz:irlirrgnosticul. () (hitete ocwlogireposl,encelalil,ice realtaeazd Im context semioloEic rrryolrlo roounoscut: {ixalea brusci,, penrbilA, coercitivd, a globilor oculi,ri rrr nrr H,itxoliid de,deflexiunea capului. MuIt mai rar se reaU;eazi un spasm hipr.r,torric latelal (cu sa} flri devialia conjugatd, a capului), Irr fpilrirn ou coborirea globilor oculari. Une6ri in cursui crize'i ""*p'*iio oolifogi"" rl, lrollu r.err)in]'&r, midriazd, sau miozd,, iar alteori bolnavul poate meniile irr cursrrl crizoi o a,titudine statuiticatd, rigid6, a intregutui c6rp. Niciodati tr Hrl(xrnst,rtd, :r,ltelarea sttrrii de conqtirn{d, in timpul crizei -(element de rllrrgrrost,iu dilorcul,ialfa{,ii, de,unr.lc crize opiloltice cir devi:r,6ia conjugaid a ;lLrlrilr. oculari itr-ilus,ou [ti1; mlli t ult, cu cit s,l|'rr d escriscrizc o-cu"logi|o ,lo ltnprrtl, tlx ricctttl rnic,,rlrtlti"l trnt'olo Iixrnzii in tlcvia!,io sursllnvor.gcll,:1, l{}Ii2)^(lrizu ll,isrrr', ilr., lrr g.rrtiHtl, rlrrrl,l,ilIutrgl (ri. lr, tiit.ovrr 'trulogi.i"r, ,rr ; ri rri i, llr cittrt'lr rrrrrrrr1 orr'), llrtlirul Ii rtrtcori rrrplirnir,tr'l volrr rrtlrr,,tlirr. llrr

ol ti tl t' i tttr6t r lt tt t t li l; t t t t |'t t t t t rio t gi la,ir lt r t it t isl, r illol r lr r lllt lllr . it , lo r lo : t 1, r o1r ilr ii, rl l tu N cr ruol: r , rr it rji, . I llrlu,nnptsrtt..nl. si sltttsrnu,l.faaio,t, ltn,i<t lirlicli, irrr.Jrorl,lrrrl(r , .rl) I)|.6I)Ir\|r||, r.lurlirugrroslic, pul,irul li explorirl urrol rnllnil'estliri spasticrr p'riprr.rrlizi. Irt,ciu,L'i,, a unnl rnrr,nifesi,Lriextrapirarnidille, s.m lunc!,iotur,lc, irrdrisiv gril,i
i r h(i {).

a) Crampa scriitorilor se caracterizeazti, plintr-o contr'tt'otuI'ii1[rsa,grrlii,, . ,,(,ora,1;ivi,, a murschilormiinii (uneori [i ai antob]'atului), cu otisplu orr, irr liipr,r.' l'kr.r ie a.degetelor, care apare in co!ciilii binc rteteuninate ;i rih,l iv irlorrtlir.r,, respectiv in mornentelein care boLnavul incepe si, sctic. ()r'runj)1, rsl,rrrlrrlr, lol,sri ,5ise extinde adeseaqi la mugchii brafului, ai umintlrri ryirr,igilrrlrrr. Do aele mai multe ori este vorba de crampe ,,funcfionalo,, irrrrlrisiorrrl,, (Lr, drctilografe,-la_funclionari,la pianiqti, la violoniqti oto.), irr llrrriti,rr l iili distonice declanqateqi/sau exacerbate de o fobie a stir,isulrri r-i:rrr :r prlctici,rli profesiunii lii de o fatigabilitate excesiv5. Unrxllj insii csl,o vollrr, rlo o diskinezie eltrapiramidali,, sugeratii, incii de Il,iser (19f2) qi vrr,it.icr tl, clectromiograflc de Aqgian gi Popovi.iu ( 1980). Astfel, se pructirli, cx i r,l rrl trrI l)lIG simxltan atiL pe rgoniiti. cit,li po i],ntagoniltifprrrt,rr,,irrr.r.v;r(.r,.r r'e,'iptocc "). In crampr, ncrrolicS,, la accaslA plobl'r :r , , i rIr.r'v r, 1ic i lr.r.r o funclionalitate normlh, ln sclsul i:i ll, txrrr lrtoce)t.se tlepisteazS, l,r.:rr.(irr rgoni,ltilor se constat[ decontraclia antlgoniptilor. fn schirnb, rlrrrii r.ii,, vor'lla de o ditq.kinezie extrapiramiclali,, Ia contracl,ia rgorriFi,iiol sr, r,r,rr l.r'tct[ .$i rnu$chii antagoni;ti, adici. apare o activitnte EM(i ;i 1xr l,r,rrsr,rrl rrrrr;ohiului antagonist, inregistratd in mod simultan cu cont,r.l,c irr, rlrr rr,. 1, 1r'rr,soul EMG.al muqchlului agonist..Credemcd, aceastii, prob;i lrlozirri;r,'o lrrkrilre semiologicS,pen!ry diagnosticul diferenliat intldcrarnpirlo rrrrvlo I irrr si ccle extrapiramidale ,si pentru olientarea tratamentnhii. l)..I.n (boala Lui Steinert i boala lui Tltomsen) ln o\ir,rrr\rl -m,iotonii, ,rrr;rr'r'licial ne-ar putea duce in eroa,te,sugerindu-sein mod irr<rorrrcl, r,ri r.rilr vorba de o lripertonie. De fapt,.dupii,cums-a precizai,irr uli,irrrir:rrri, .,irr ciiLdaaparenlelor qi contrar definiliei clasice,miotonir.r, nu cshr o lrrl lrrrrrr'ode relaxare, ci o contractie prelungiti, determinatri do irclivil,rrl,r,rr, I r.ir x'lcetricS" interactiv[,_suslinut[ a sarcolemei" (Radu, 19?ll). l)i:rgrrorr Iicrrl este relatiy u$or de stabilit, gratie ulm5,toarelor elomcn{,o: Caracterul eredo-familial atit al miotouiei congenittlo hipori,r.ol.ico (lxrrla lui Thomsen), cit qi.aI distrofioi miotonice,(bo;la lui Si;oirror.i); - Prezenla hipertroiiei maselor musculare irL boa,la lui ll,horrrxoirur :r rll;rofijLor musculare in troala lui Steinert; -.Prezenf,a fenomenului miotonic, care se gtio cri nu ptozint:L torrru,rir iu lotrsitate in toato grupelo musculare.Astfel, sc poate lo-rnl,r,cir r, lrr.rrrlrr rrrirrlnll a fenomenului miotonic la musculatura <listllii a lnorrrlrr,il,,r_'1,, rriol,oni:l,conge_nitald,. (Thomson).fenomenul mioto ic aprlro gorrot,:[lizlr,l,, rr vrome cc in distrofia miotonicir, Steinert este mai limitat, alleirlirrrl r|rrr,r" cilivr,.muqchi sau grupe muscuhre (mugchii policehti, rnuqrchiilirrrlrii, rrrrrqrhiiflexori ai rlegetolor,'mu;ch i i orb!culali ui ploo.r,pol rr.ryi odukrrrrol,or.ii). lrr lrrr |rlmiol;onia congonitalii t, Iui. rlult'nl; rrrg lerrr)luernrlrniol,rtrrio porrl,r, rrrlclcsil ln rnorl oxclusiv nruqchii faoiali (lilrilu, l-9?8); (l rr,srr,lvoirrriokrni0rrriir,r.rr, -- or)rrBi,rIlil 'ol, Iil 0xir,rrr{)nIllr)l\l rrI,r, r.i rrI rrrrr (rrt rlrrt'lulil, pilrr'i, !l) s), corrrl,il,uili, lrr, tlirr pot,rrrr{,ilr,lrr lrlxri,il,ivsqr!r{, r,rl,r{rr irr rrrlpliirrrlirro qi irr lrrrrrvrrrr{r'i, ;Irr'rllr'l' rr,irrrrrinrlrr xrrrDoi irrrr'rr i,r.rr,rfH
(x,n{ l (' l (' l tl , ; ... l ' t' .zr f alir , r .i r rrI r , rrr rrI rri r , r r r lr r r . r 'itit r r lill. r r lir r , r r r i, i, r r i. ir , lJi, r r ir r r r l. i. l Tft

,l.I.ll. lli;lorlorriilc ptrrrrrrrrr^rrlo (srrbtrrrlc si r,ronica) I I .iilt.l't oniil,e ruh,itliute (rtthitotaiile) clu,yproase .scpot intiLni 'l-:!.:1.1. Ntcctiiuni: ir rrrrr rotoir,se t) ilinrlrotnul mentnge&l,realizat de meningite qi de hemola,giilo subiurlrrr)irli('no implici, in tabloul semiologico hipeltonie dureroa,s5,, ertinsii irli'${,ir lir i,u{,i muqchii cen'icali postedori qi ra;hidieni dorso-1i:mbari, insoin ,,cocory de puqci', Liiri (l(l rlxloarea neiii, a cefei, de pozilia cancterisl,icd, 1i pozil,ivil,ater bingcunoscutelor manevre Kcrnig f , Kernig trI, Lasdgue, I, Rrudzinski II ry.a. llrrrrlzitrslii pseud.o-nz,eningeu,l, al f6ei posterioara trebuic dilerenbiat lt) tlii,ttdromu,l rlc sinilrrrilmelc meninge,alepropiiu-zise. Acest sindrom pseudo-lr cningeal de proceselocalizate in fosa postelioari,, dal' qi de altc proiese cslr, rr.rrlJzat r.)il):ll)sivc supratentodale, ca,re produc fenomene de angaja,re a cercbcr lobului temporal. Se poate astfel evidenlia, o ledoare trrlrri, r',.spor.tiv rlrur.r',rrsi rahitli.tuii celvico-dorsalScu Bemnul lui Kernig prezeut, cu o lrozilio rleflectati| a capului, cu membrele inferioare in flexie, cu atitudine hiper-tonie dureroasi, a cefei qi a rahisllr ,,(xxiol de puqci'". l)ar aceastS, prezenta exacerbiri qi remisiuni, fiind va,riabili in iritensitate, ia,l Irri porrl,e rrrrrrrlirr lornbard, (periculoasi in aceste situalii) poate s5, tie urmat5, de o lr.rrlrrrlrsot:nli a, algiilor occipito-cernicale $i a semnelor meninge:lle. Un lrtont ,i sistenatic al fundului de ochi este susceptibil sd,previn6, r.rrrrrrr,n
il g('rrrclloln el'oll.

o l l i z r r l o r r r l r L , o ;r i r r tu r l l i r ,i , tr u r u r ti , t,l tr tt o ttr l tti r , l tr l r i l r r ( l i i r tt, l l l l ,l '; , \ t r r . t t i r i r , , o l r l r .. l 1 l i ,l ) . r l r r l r i i cr tr r l l l i It.l l l l i r ( , \ r , t , l r s l , j i r r ,r l o :tr tr l t ccl i r i so l l o l tl o Iu Ir r r 1 r L r |,Ir ,, : u r 1 {r i o l , 0 u o tr l l si t,i ( ,o n tl l o 1 ,n I'i 'i , l t, i tr l ttl l Ji ( x) l o i r l tcr l ) l ( r r tn t si ttt r u zl t, l o n j c c t l e s c l i so tl c Ja ckso tL q i i l e Ar scn i .si tu r l ttl t. 'l 'tr r l l tti o ;i r tr r {'i ttt'ttt t'i r .

cslo tl ttt. nurlc irnportanlii plactioii prezinli ttlplul cti turbilizrllor, cruprtltri IMI||il|iiIr I |orrs[ qi ci, se inso-teSte foarte frooYont d.o paloiil'(], q1('1ilr|j. rtri'tiginoase qi rnociifie5ri carclio-vasculale qi iespir:l'1,ot'ii. t il Jntt,stulqlu sau bi,laterale,localizate, u'lecol.outtti.1i. d) Contraeturitt'nipot fi intilnite in cele mrti tlivr:tsr':tllr'1 t:erticale, tkrrsale;i d,orso-lombare uni ale coloanei (spondiloze,spondilite, puseuri de rertntalisttt t'titLrr|rtrrI trrri, c lt rrI rr hr:rnii dc disc, tumori vertebrale), dar si in alte proccse(aLrccsc lito do diver"seetiologii, arahnoidite, meningoradiculitc lo<rtlizrrlr,,'r.:r., \u trebuie si uitim nici inqeli,torul ,,lumbago primifiv llrrlrrtrrqrh.gir ' rlesclisde Sicard (citat de liiser, L952) c semu dedebut (fazi, t rrt I i rrrrIrrr':' r rir cvolulia unor tumori extradulale satr subdurale, in snre insii sitttlt0ttrrr] {r r iltr 1r.tr uranometric qi cito-chimic lichidia,n de blocaj rahidia,n sint rr1 l:r'an$areadiag:rosticului. (ernrrr.li:.trl, 4,2.2,2. Hfutertoni.il,e{ t:onlraclurile ) d,e origi.nece,ntraLri tuzt. toc,alizate) a) trIfuiertonia (contractura) piramidald prezintd, p:llticul;r,riiil {iLr lrirr, (lnnoEcute:predominanld ectromelic5,; caracter electiv sau (1r'irsir'l(\'lr\ (1troponderenl,i pe flexod $i pronatod la meinbrele supeljoar'(',r.rp(,rl r\ inferioare) ; atitudinea caxactcristicii a,lnrr r lr rr,l,,r la membrele ertensori 1rc r,l,', intcresate (de tip Wcmicke Mann), consecutivi acestoi contl'i|,(,1,rrIi li1'e; prezenla sincineziilor (globale, de imitalie ;i de conjuga!,io) I crrlrrl Icrtl de cedate ,,continu5," qi elastici la probele de mobilizrlrt prrrrivl lopograiia extinsS, hemiplegici,, para,plegici', tetraplogici' sau monopk',;1icrr plczenla altot semne pirarnid.aie. Caracterele propdi ale hipertoniei (contracturii) pilanlidillc lrr p('f rrrit aprecierea topogratiei leziunii qi ca, at'are, un aieosellit itLtu(.s lt)lt)ttt'tl /ic ]rrezintd,semneleasociate ,,de etaj" (spina1e, de tnnchi cctclrlrrl, rtrr licrLle,subc